Deep vein thrombosis and pulmonary embolism

Incidence of Venous Thromboembolism Post-Oral Anticoagulation Reversal in Intracranial Hemorrhage Patients

BACKGROUND

Rates of in-hospital venous thromboembolism (VTE) in the intracranial hemorrhage (ICH) population post oral anticoagulation (AC) reversal are as high as 10%. Guidelines recommend the initiation of prophylactic AC 24 to 48 hours post ICH; however, there is no guidance regarding optimal VTE prophylaxis post-reversal.

OBJECTIVE

This study aimed to identify the incidence of thromboembolism post oral AC reversal in patients presenting with ICH and describe VTE prophylaxis timing and agent selection.

METHODS

This was a retrospective, descriptive study conducted within a single health system. Patients on AC who received reversal agents 4-factor prothrombin complex concentrate (4F-PCC) with or without vitamin K, andexanet alfa, and/or idarucizumab for AC-associated ICH were included. The primary endpoint was incidence of in-hospital VTE post-reversal. Secondary endpoints included AC utilization specifications, length of stay, and in-hospital mortality.

RESULTS

There were 118 patients (57%) who received 4F-PCC and 89 patients (43%) who received andexanet alfa for reversal post-ICH. Overall, 195 patients (94.2%) achieved hemostasis. Eight patients had incidence of VTE (3.9%), and of those, 6 patients (75%) were reinitiated on AC, all of which utilized prophylactic heparin. The median time from reversal to VTE was 55.9 days (interquartile range [IQR] = 21.2-72.4). For all patients on AC, the median time to initiation from reversal was 3.98 days (IQR = 2.5-6.01), and for those with incidence of thrombosis, the median time to AC initiation was 6.4 days (IQR = 2.6-13.1). Mortality occurred in 13 patients (6.3%).

CONCLUSION AND RELEVANCE

This patient population is complex in that the need to achieve hemostasis with AC reversal must be balanced with the risk of VTE. Further studies are needed to determine the ideal timing and agent selection for VTE prophylaxis initiation post ICH reversal.

Barriers and facilitators to the implementation of guidelines for venous thromboembolism prevention and management: A mixed-methods systematic review

Background

Evidence-based venous thromboembolism prevention and management is a priority for global health services. Low adoption of venous thromboembolism guidelines can result in compromised patient outcomes. Understanding clinicians' and patients' perceptions of barriers to and facilitators for guideline implementation and mapping identified barriers and facilitators to the Consolidated Framework for Implementation Research may inform theoretical interventions to improve guideline adoption rates.

Objective

To synthesize quantitative and qualitative evidence on both 1) perceptions and experiences of hospital clinicians and patients regarding venous thromboembolism practices and 2) barriers to and facilitators for guideline implementation.

Data source

English-language studies from MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane published between 2012 and 2023.

Methods

The included studies primarily focused on two aspects: firstly, elucidating the perceptions and experiences of healthcare providers and patients concerning venous thromboembolism management practices, and secondly, identifying the barriers and facilitators that influence the implementation of venous thromboembolism guidelines. The Mixed Methods Appraisal Tool was used for critical appraisal. Quantitative data were transformed into qualitized data and then thematically synthesized with qualitative data to compare the perspectives of clinicians and patients. Barriers and facilitators related to each topic were mapped to the Consolidated Framework for Implementation Research, and the barriers were entered into its implementation strategy matching tool to obtain implementation strategies.

Results

Of 8262 studies of varying quality, 26 (20 quantitative, five qualitative, and one mixed-methods) met the inclusion criteria. Four themes represented factors influencing guideline implementation: 1) healthcare-led multidisciplinary prevention and management, 2) feasibility of guideline implementation, 3) patient involvement in prevention and management, and 4) government and hospital environments and related systems. The majority of barriers identified by healthcare providers were related to the second and fourth themes, while for patients, there were multiple barriers under the third theme. Barriers were mainly mapped into four domains: intervention characteristics, outer setting, inner setting, and characteristics of individuals. Most facilitators mentioned by healthcare providers and patients were related to themes 1, 3, and 4 and mapped to three domains: outer setting, inner setting, and characteristics of individuals. Seven optimal implementation strategies were obtained through the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change matching tool.

Conclusions

We highlighted the most influential factors associated with implementing venous thromboembolism guidelines from the perspectives of both clinicians and patients, and mapping these factors to the Consolidated Framework for Implementation Research can help to develop stakeholder-appropriate implementation interventions.

Registration

This study's protocol has been registered at PROSPERO under the registration number CRD42024518184.

Therapeutic targets for venous thromboemblism: proteome-wide mendelian randomization and colocalization analyses

BACKGROUND

Venous thromboembolism (VTE) is a significant global health issue, yet effective therapeutic targets for its prevention and treatment remain elusive. This study aimed to identify plasma proteins causally associated with VTE risk using proteome-wide Mendelian randomization (MR) and colocalization analyses.

METHODS

We utilized genome-wide association study (GWAS) data from the UK Biobank and FinnGen cohorts, encompassing 38,573 VTE cases and 946,373 controls. Plasma protein levels were quantified using Olink technology in the UK Biobank Pharma Proteomics Project (UKB-PPP) and SomaScan in the deCODE Health study. MR analysis was performed to assess causal relationships, followed by colocalization analysis to evaluate shared genetic variants. Functional enrichment analyses and molecular docking were conducted to explore biological mechanisms and predict potential therapeutic compounds.

RESULTS

Eight proteins showed significant associations with VTE risk after Bonferroni correction (p < 3.19 × 10-5). Odds ratios ranged from 0.98 (95% CI: 0.98-0.99) for PLEK to 1.03 (95% CI: 1.02-1.04) for LRP12. Strong colocalization evidence (PH4 ≥ 0.8) was found for LRP12, F11, PLCG2, and ABO. Molecular docking identified promising drug candidates including valine, folic acid, ibrutinib, and simvastatin, with valine showing the strongest binding energy (-32.057 kcal/mol).

CONCLUSIONS

This study highlights novel therapeutic targets for VTE and provides insights into potential drug candidates. These findings offer a foundation for future research and drug development aimed at reducing VTE risk.

Incidence of deep venous thrombosis following medial opening-wedge high tibial osteotomy for varus knee osteoarthritis: a retrospective study

PURPOSE

Deep venous thrombosis (DVT) is a common yet underexplored complication following medial opening-wedge high tibial osteotomy (MOWHTO) for medial compartment knee osteoarthritis. Existing studies report inconsistent findings due to methodological differences and patient heterogeneity. This study aims to determine the incidence and risk factors for DVT after MOWHTO.

METHODS

We retrospectively reviewed patients who underwent MOWHTO for medial compartment knee osteoarthritis with varus deformity between January 2019 and September 2023. Patients were classified into DVT and non-DVT groups based on Doppler ultrasonography findings. Univariate analysis was performed to compare demographics, lifestyle factors, comorbidities, surgical details, and laboratory results on postoperative day 1 between the DVT and non-DVT groups. Receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to evaluate the predictive performance of laboratory indices for DVT. Multivariate logistic regression model identified independent risk factors for DVT.

RESULTS

Of the 421 patients (median age: 56 years, interquartile range: 52-61 years; 146 males), 55 (13.1%) developed postoperative DVT. The incidence rates for isolated calf muscle vein thrombosis (ICMVT), deep calf vein thrombosis (DCVT), and proximal DVT was 10.7%, 1.9% and 0.5%, respectively. Most laboratory indexes demonstrated non-significant (P > 0.05) or poor (AUC < 0.70) predictive performance, except for AT III and FDP (p = 0.022, 0.033, respectively). The multivariate logistic regression analyses showed female (OR, 2.23; 95% CI, 1.09 to 4.63), diabetes (OR, 2.47; 95% CI, 1.15 to 5.40) and hyperlipidemia (OR, 1.91; 95% CI, 1.14 to 3.68) were significantly associated with postoperative DVT.

CONCLUSION

This study identified a high incidence of DVT following MOWHTO and demonstrated that female sex, diabetes and hyperlipidemia were significant risk factors. These findings may inform better risk assessment, stratification and management of DVT.

CLINICAL TRIAL NUMBER

Not applicable.

Proximal venous ultrasound with risk stratification safely excludes deep venous thrombosis in emergency department routine care: an observational study

BACKGROUND

Lower limb deep vein thrombosis (DVT) is common in emergency departments (EDs) and can be fatal if left untreated due to the risk of progression to pulmonary embolism (PE). In Scandinavia, DVT diagnosis typically relies on ultrasound performed outside the ED in the diagnostic departments. However, international guidelines now recommend combining limited/proximal compression ultrasound of the lower extremity PUL with risk stratification as a viable approach for diagnosing and ruling out DVT. The aim of this study was to evaluate the safety of ruling out DVT by integrating PUL with risk stratification in ED routine care.

METHODS

This observational cohort study was conducted at the Helsingborg Hospital ED, Sweden, from April 2022 to November 2024. Adult patients with suspected DVT underwent PUL combined with risk stratification using the Wells score. Risk stratification, PUL findings, diagnosis and management plan were prospectively recorded. A 30-day follow-up was conducted to identify any subsequent DVT, PE or deaths registered as caused by PE post index visit. Patients prescribed anticoagulation following an ED-diagnosed DVT were followed up at 3 and 6 months to monitor for major bleeding events.

RESULTS

A total of 560 patients were evaluated, with an overall DVT prevalence of 18.4%. Of these, 471 patients (82.5%) were managed entirely within the ED, without referral to the diagnostic department. Of the 381 patients discharged from the ED with DVT ruled out (negative PUL and low risk assessment), two were diagnosed with DVT or PE within 30 days. This resulted in a negative predictive value of 99.5% (95% CI: 98-99.9%) and a sensitivity of 97.8% (95% CI: 92.4-99.7%) for PUL combined with low-risk stratification in ruling out DVT. One of the 90 patients diagnosed with DVT in the ED and prescribed anticoagulant therapy experienced a major bleed related to an in-hospital procedure.

CONCLUSIONS

In this single-center ED study the combination of PUL and risk stratification in routine care was a safe and effective method for the early diagnosis and ruling out DVT. Using this approach, more than 8 out of 10 patients could be diagnosed in the ED without the need for external diagnostic support.

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 s ymptom 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.

TMEM132A: a novel susceptibility gene for lung adenocarcinoma combined with venous thromboembolism identified through comprehensive bioinformatic analysis

Background

Mounting evidence indicates that lung adenocarcinoma (LUAD) patients are at elevated risk for venous thromboembolism (VTE), presenting a major clinical challenge. This study utilized public databases to identify crosstalk genes (CGs) between LUAD and VTE, applied machine learning methods to discover shared diagnostic biomarkers, and explored their underlying mechanisms.

Methods

Disease-specific genes for VTE were extracted from comprehensive genomic databases (CTD, DisGeNET, GeneCards, OMIM), while transcriptomic profiles of LUAD and VTE cohorts were retrieved from GEO via GEOquery implementation. Molecular crosstalk analysis identified candidate genes through differential expression algorithms and disease-association metrics. Functional annotation employed GO and KEGG analyses to elucidate the biological significance of identified CGs. LASSO regression analysis of VTE and LUAD matrices yielded overlapping diagnostic biomarkers. Immune contexture was characterized via CIBERSORT deconvolution, followed by correlation analyses between hub genes and immune infiltration profiles. Hub genes expression was corroborated through independent cohort validation and serological quantification. Diagnostic utility was evaluated through receiver operating characteristic (ROC) curve and nomogram. Therapeutic potential was assessed via DSigDB-based drug sensitivity profiling.

Result

Through transcriptomic analysis, we identified 381 CGs, which demonstrated significant enrichment in inflammatory cascades, immunological processes, and coagulation pathways. LASSO regression analysis of LUAD and VTE cohorts revealed TIMP1 and TMEM132A as putative shared diagnostic biomarkers. TMEM132A exhibited significant correlation with immune cell infiltration patterns across both diseases, modulating the immune microenvironment. Validation cohorts and serological assessment confirmed elevated TMEM132A expression in LUAD and LUAD combined with VTE phenotypes. The diagnostic accuracy of TMEM132A was substantiated by ROC curves and nomogram analyses. Pharmacological sensitivity analysis indicated that TMEM132A may serve as a potential target for the therapeutic agents birabresib and abemaciclib.

Conclusion

TMEM132A demonstrates diagnostic utility as a predictive biomarker for VTE occurrence in LUAD, suggesting its potential role as a susceptibility gene in this patient cohort.

Comprehensive review of thrombophilia: pathophysiology, prevalence, risk factors, and molecular diagnosis

Thrombophilia, characterized by an imbalance between fibrinolysis and coagulation leading to inappropriate blood clotting, is a significant medical condition. The CDC has designated it as an underdiagnosed, serious, and potentially preventable disorder, contributing to an estimated 600,000-900,000 cases and 100,000 deaths annually in the United States. These figures surpass the combined annual mortality of AIDS, breast cancer, and motor vehicle accidents. The pathogenesis of thrombophilia involves complex interactions between genetic predispositions, such as mutations in Factor V Leiden, Factor II, MTHFR, and Serpine-1, and environmental factors, including unhealthy lifestyles, prolonged hospitalization, obesity, and cancer. Prevalence of specific genetic mutations varies across populations. Additional risk factors include age, family history, and pregnancy, with recent attention to increased susceptibility in SARS-CoV-2 infection. While molecular diagnostic techniques are available, there remains a need for robust, cost-effective, and accurate screening methods for large populations. This systematic review provides an updated overview of thrombophilia, encompassing pathophysiology, epidemiology, genetic and environmental risk factors, coagulation cascade, population-specific mutation prevalence, and diagnostic approaches. By synthesizing clinical and molecular evidence, this review aims to guide researchers, hematologists, and clinicians in the diagnosis and management of thrombophilia.

Integration of bulk RNA-seq and scRNA-seq reveals transcriptomic signatures associated with deep vein thrombosis

Background

Deep vein thrombosis (DVT) is a prevalent peripheral vascular disease. The intricate and multifaceted nature of the associated mechanisms hinders a comprehensive understanding of disease-relevant targets. This study aimed to identify and examine the most distinctive genes linked to DVT.

Methods

In this study, the bulk RNA sequencing (bulk RNA-seq) analysis was conducted on whole blood samples from 11 DVT patients and six control groups. Topology analysis was performed using seven protein-protein interaction (PPI) network algorithms. The combination of weighted correlation network analysis (WGCNA) and clinical prediction models was employed to validate hub DEGs. Furthermore, single-cell RNA sequencing (scRNA-seq) was performed on peripheral blood samples from 3 DVT patients and three control groups to probe the cellular localization of target genes. Based on the same methodology as the internal test set, 12 DVT patients and six control groups were collected to construct an external test set and validated using machine learning (ML) algorithms and immunofluorescence (IF). Concurrently, the examination of the pathways in disparate cell populations was conducted on the basis of the CellChat pathway.

Results

A total of 193 DEGs were identified in the internal test set. Additionally, a total of eight highly characteristic genes (including TLR1, TLR7, TLR8, CXCR4, DDX58, TNFSF10, FCGR1A and CD36) were identified by the PPI network algorithm. In accordance with the WGCNA model, the aforementioned genes were all situated within the blue core module, exhibiting a correlation coefficient of 0.84. The model demonstrated notable disparities in TLR8 (P = 0.018, AUC = 0.847), CXCR4 (P = 0.00088, AUC = 1.000), TNFSF10 (P = 0.00075, AUC = 0.958), and FCGR1A (P = 0.00022, AUC = 0.986). Furthermore, scRNA-seq demonstrated that B cells, T cells and monocytes play an active role in DVT. In the external validation set, CXCR4 was validated as a potential target by the ML algorithm and IF. In the context of the CellChat pathway, it indicated that MIF - (CD74 + CXCR4) plays a potential role.

Conclusion

The findings of this study indicate that CXCR4 may serve as a potential genetic marker for DVT, with MIF - (CD74 + CXCR4) potentially implicated in the regulatory mechanisms underlying DVT.

Neutrophil extracellular traps induced by neoadjuvant chemotherapy of breast cancer promotes vascular endothelial damage

BACKGROUND

The mechanisms underpinning neoadjuvant chemotherapy-induced vascular endothelial injury in breast cancer remain elusive. Our study aims to demonstrate that Neutrophil Extracellular Traps (NETs) play a pivotal role in neoadjuvant chemotherapy-induced vascular endothelial injury in breast cancer, elucidating that chemotherapy-induced upregulation of Solute Carrier 11a1 (Slc11a1) modulates Reactive Oxygen Species (ROS) generation, which may be critical for NETs formation.

METHODS

We investigated the impact of neoadjuvant chemotherapy for breast cancer on NETs formation and vascular endothelial injury by analyzing NETs dsDNA and serum markers in patients, cells, and chemotherapy mouse models. RNA sequencing of neutrophils from chemotherapy mouse models was performed to identify the potential NETs formation-associated gene Slc11a1, which was further validated through cellular and animal experiments by assessing Slc11a1 expression, intracellular ferrous ion content, and ROS levels. Knockdown of Slc11a1 in human neutrophils and mouse models were also performed to further confirm the phenotypic results.

RESULTS

Our study revealed that plasma NETs formation and endothelial injury markers were significantly elevated in breast cancer patients undergoing docetaxel & carboplatin (TCb) neoadjuvant chemotherapy, compared to controls. In these patients, NETs formation was associated with the augmentation of endothelial injury markers. Chemotherapy mouse models demonstrated that TCb treatment markedly elevated NETs formation and endothelial injury, which can be mitigated by CI-amidine, a protein-arginine deiminase inhibitor. In human neutrophils, we demonstrated that the TCb chemotherapeutic agents (combination of docetaxel and carboplatin) induced the formation of NETs, which subsequently facilitated damage to human umbilical vein endothelial cells in vitro. RNA sequencing of mouse neutrophils identified Slc11a1 as a key NETs formation-related gene, which was upregulated by TCb chemotherapy in neutrophils, leading to increased intracellular ferrous ion content and ROS generation. Knockdown of Slc11a1 in human neutrophils and mouse models demonstrated its reversal effect on TCb-induced ferrous ion upregulation, ROS generation, and NETs formation.

CONCLUSIONS

Our research underscores the capacity of TCb neoadjuvant chemotherapy in breast cancer to augment NETs formation in neutrophils through Slc11a1-mediated ROS generation, which is linked to vascular endothelial injury. Our study elucidates the potential mechanisms underlying perioperative vascular endothelial injury in breast cancer patients undergoing neoadjuvant chemotherapy, offering novel insights into perioperative therapeutic management strategies for these patients.

Oral anticoagulant use among Medicare patients newly diagnosed with venous thromboembolism (VTE): Factors associated with treatment status

OBJECTIVE

This study aimed to describe oral anticoagulant (OAC) use among patients with venous thromboembolism (VTE).

MATERIALS AND METHODS

This study included Medicare fee-for-service beneficiaries (data from 1/1/2014-12/31/2019) newly diagnosed with VTE. Factors associated with being untreated with OACs in the first month from VTE (vs. OAC-treated), with receiving direct-acting OACs ([DOACs] vs. warfarin), and with extended OAC treatment (>3 months) were assessed using multivariable logistic regressions.

RESULTS

Overall, 169,928 patients with VTE (50.3% OAC-untreated) were included. Among the 49.7% OAC-treated patients, 74.0% used DOACs and 62.5% had extended OAC treatment. Factors associated with being untreated with OACs in the first month from VTE (odds ratio; 95% confidence interval) included Hispanic ethnicity (vs. White;1.35; 1.29-1.42), having part D low-income subsidy (1.14; 1.07, 1.20), and comorbidities such as cardiovascular diseases. Among the OAC-treated cohort, patients with index VTE diagnosis in the emergency room (vs. outpatient) setting had higher odds of receiving DOAC vs. warfarin; patients with pulmonary embolism diagnosis (vs. deep vein thrombosis) had higher odds of extended OAC treatment.

CONCLUSIONS

In this study of Medicare patients newly diagnosed with VTE, half of the patients were not treated with OAC in the first month from initial diagnosis. Factors such as Hispanic ethnicity, having low-income subsidy, and comorbidity burden were found to be associated with being untreated with OAC. Among OAC-treated patients, the majority were treated with DOAC vs. warfarin. Interestingly, more than a third of OAC-treated patients were not treated beyond 3 months, which warrants further investigation.

A nomogram for predicting risk factors for lower limb deep venous thrombosis in elderly postoperative patients with severe traumatic brain injury in the intensive care unit

AimTo investigate the incidence and risk factors for lower limb deep venous thrombosis in elderly postoperative patients with severe traumatic brain injury in the intensive care unit.DesignA retrospective study.MethodsFour hundred and one elderly patients (defined as aged ≥60 years) with severe traumatic brain injury who had undergone surgery and were admitted to the intensive care unit were enrolled in this study. We collected data on the incidence of lower extremity deep vein thrombosis and analyzed its influencing factors. Binary logistic regression analysis was employed to assess the associations between these factors and the occurrence of DVT. A nomogram was developed, and calibration curves were utilized to evaluate the model's accuracy. Additionally, a receiver operating characteristic curve was employed to assess the model's clinical discriminatory power.ResultsThe incidence of lower limb deep venous thrombosis in elderly postoperative patients with severe traumatic brain injury in the intensive care unit was 25.69%. The final nomogram included age, intraoperative hypothermia, intraoperative bleeding volume, surgery time, D-dimer level, any organ failure, and body mass index as independent risk factors. The standard curve fit well with the calibrated prediction curve. The area under the receiver operating characteristic curve was 0.976 (95% CI: 0.958-0.994), and the model had good discrimination ability and reliability.ConclusionsThe risk factors for lower limb deep venous thrombosis in elderly postoperative patients with severe traumatic brain injury in the intensive care unit can be preliminarily assessed via the nomogram prediction model. This information may help guide medical staff in making reasonable decisions regarding the management of deep vein thrombosis prophylaxis.Patient or Public ContributionElderly postoperative patients with severe traumatic brain injury in the intensive care unit participated in the retrospective investigation of this study.

Acute pulmonary embolism with and without hemodynamic instability (2003-2022): a Swiss nationwide epidemiologic study

BACKGROUND

Data on the epidemiologic burden of acute pulmonary embolism (PE) in Switzerland are unavailable. Knowledge gaps remain on trends in PE-related comorbidities, PE severity, and length of in-hospital stay (LOS) at a nationwide level.

OBJECTIVES

To study the epidemiology of acute PE with a focus on overall trends, sex-stratified trends, and trends in patients with (vs without) hemodynamic instability.

METHODS

We used nationwide, patient-level data including all patients aged 15 years or older hospitalized for PE in Switzerland from 2003 to 2022, amounting to N = 180 600. Additionally, we analyzed the Swiss Death Registry for the same period. We estimated the disease-specific age-standardized incidence rates, mortality rates, in-hospital case fatality rates, proportional mortality rates, and LOS. Analyses were stratified by sex and the presence of features of high-risk PE.

RESULTS

During the study period, the PE-related incidence rate increased from 0.87 (95% CI: 0.82, 0.92) per 1000 population in 2003 to 1.19 (95% CI: 1.15, 1.24) in 2022. In contrast, a decreasing trend was found for mortality rates (18.7 [95% CI: 16.8, 20.6] per 100 000 population in 2003, 13 [95% CI: 11.7,14.2] in 2022), in-hospital case fatality rate (9.8 [95% CI: 9.1, 10.5] deaths per 100 hospitalized PE patients in 2003, 7.9 [95% CI: 7.4, 8.5] in 2019, subsequent increase during COVID-19 pandemic), and LOS (11 [Q1-Q3: 7-18] days in 2003, 8 [Q1-Q3: 4-16] in 2022). No major sex differences in trends were present. Except for LOS reduction, patients with high-risk features presented with similar trends.

CONCLUSION

The incidence of acute PE in Switzerland increased over the last 20 years. Despite increasing trends in the median age at PE diagnosis, in-hospital case fatality and mortality rates decreased, particularly among patients with high-risk features, and the LOS progressively declined.

Additive Value of Right Ventricular Global Longitudinal Strain to a Conventional Echocardiographic Parameter to Improve Prognostic Value in Intermediate-Risk Pulmonary Embolism

BACKGROUND

Right ventricular (RV) dysfunction has been identified as a prognostic marker for adverse events in patients with intermediate-risk pulmonary embolism. We hypothesized that right-sided strain parameters have additive value to conventional echocardiographic parameters to further risk-stratify patients for mortality.

METHODS AND RESULTS

This is a retrospective cohort study of patients with intermediate-risk pulmonary embolism between 2010 and 2018. All-cause 30-day mortality was evaluated. Echocardiographic strain parameters and conventional RV measurements were compared between survivors and nonsurvivors. Two hundred fifty-one patients were analyzed. Mortality at 30 days was 12.4%. Image quality was sufficient for RV strain analysis in 230 patients (91.6%). Right to left ventricular end-diastolic diameter ratio (RV/LV ratio) (odds ratio [OR], 1.490 [95% CI, 1.120-1.990]) and RV global longitudinal strain (RVGLS) (OR, 0.742 [95% CI, 0.605-0.910]) were independently associated with 30-day mortality. Using RVGLS and RV/LV ratio in an additive fashion, we found that 99 patients with a high RVGLS (>17.7%) and low RV/LV ratio (<1.03) had a 30-day mortality of 1.0%. Conversely, 39 patients with a low RVGLS (≤17.7%) and high RV/LV ratio (≥1.03) had a 30-day mortality of 46.2%. Kaplan-Meier analysis depicted the significantly different prognosis among the groups (P<0.001).

CONCLUSIONS

The combined evaluation of RVGLS and RV/LV ratio is a practical method of evaluating RV dysfunction. Using both parameters in patients with intermediate-risk pulmonary embolism identifies those at highest and lowest risk of short-term mortality. This approach offers promise for improved risk stratification and guidance of treatment pathways.

Concurrent Acute Limb Ischemia and Pulmonary Embolism in an Adult With Repaired Tetralogy of Fallot: A Case Report

Simultaneous acute limb ischemia (ALI) and pulmonary embolism (PE) are extremely rare, with the current literature providing a limited understanding of shared mechanisms. We report a rare case of concurrent ALI and PE presentation in a patient with a history of repaired tetralogy of Fallot (TOF), emphasizing the possible association between congenital heart disease and thromboembolic risk, potentially through residual hemodynamic abnormalities or arrhythmias. The case involves a 48-year-old male with a history of TOF repair in childhood who developed simultaneous ALI and PE approximately 48 years after the surgical repair. The patient presented with sudden right lower extremity pain and swelling; was classified as Rutherford IIa ALI; and underwent urgent endovascular revascularization that included an overnight tissue plasminogen activator infusion and a relook angiogram the next day. During admission, the common embolic etiologies of his presentation were excluded by multiple investigations, including transthoracic echocardiography, thrombophilia panel, and occult malignancy screens. Although the patient had multiple cardiovascular risk factors, including obesity, smoking, and hypertension, it is most likely the history of TOF repair that contributed the most to the concurrent thromboembolic presentation, especially given that TOF repair has been reported to be associated with chronic complications in adult patients, such as persistent right ventricular dysfunction and arrhythmias. A multidisciplinary team of interventional cardiologists, pulmonologists, and hematologists managed the case, reflecting the difficulty of managing concomitant thromboembolic events and monitoring and evaluating thromboembolic risk factors for treated congenital heart disease, most specifically TOF, in adult patients.

Safety Study of Anticoagulants for Preventing Deep Venous Thrombosis after Intracerebral Hemorrhage: Data from the Chinese Stroke Center Alliance

OBJECTIVE

The use of anticoagulants to prevent deep vein thrombosis (DVT) after intracerebral hemorrhage (ICH) remains controversial. This study aims to evaluate the safety of anticoagulants in preventing DVT in patients with ICH.

METHODS

Data were sourced from the Chinese Stroke Center Alliance. The primary outcomes include in-hospital mortality, intracranial hematoma evacuation, and hematoma expansion. Absolute standardized differences (ASD) are used to assess differences between groups, and multivariate logistic regression analysis is employed to analyze correlations. Platelet counts and international normalized ratio (INR) were examined within subgroups. Propensity score matching (PSM) is used for sensitivity analysis.

RESULTS

A total of 56,633 patients with ICH were finally enrolled. Multivariate logistic regression analysis revealed that anticoagulant use correlated with reduced in-hospital mortality and hematoma expansion (OR: 0.59, 95% CI: 0.50-0.69, p < 0.001 and OR: 0.55, 95% CI: 0.41-0.73, p < 0.001), while no association was observed with intracranial hematoma evacuation clearance (OR: 1.00, 95% CI: 0.93-1.08, p = 0.941). Subgroup analysis revealed an increased risk of intracranial hematoma evacuation with anticoagulant use when INR >1.7 (OR: 1.47, 95% CI: 1.15-1.89, p = 0.002), but not of in-hospital mortality (OR: 1.20, 95% CI: 0.78-1.85, p = 0.409) or hematoma expansion (OR: 0.66, 95% CI: 0.19-2.25, p = 0.503). PSM yielded consistent outcomes.

CONCLUSIONS

Post-ICH anticoagulant therapy to prevent DVT is safe, posing no heightened risk of in-hospital mortality, intracranial hematoma evacuation, or hematoma expansion. However, caution is warranted in patients with coagulopathies.

Pulmonary embolism after shoulder surgery: Is it a real threat?

Pulmonary embolism (PE) is a rare but devastating complication of shoulder surgery. Apart from increased morbidity and mortality rates, it may significantly impair postoperative recovery and functional outcome. Its frequency accounts for up to 5.7% of all shoulder surgery procedures with a higher occurrence in women and patients older than 70 years. It is most commonly associated with thrombophilia, diabetes mellitus, obesity, smoking, hypertension, and a history of malignancy. PE usually occurs secondary to upper or lower-extremity deep vein thrombosis (DVT). However, in rare cases, the source of the thrombi cannot be determined. Prophylaxis for PE following shoulder surgery remains a topic of debate, and the standard of care does not routinely require prophylactic medication for DVT prophylaxis. Early ambulation and elastic stockings are important preventative measures for DVT of the lower extremity and medical agents such as aspirin, low-molecular-weight heparin, and vitamin K antagonists are indicated for high-risk patients, long-lasting operations, or concomitant severe acute respiratory syndrome coronavirus 2 infection. The most common symptoms of PE include chest pain and shortness of breath, but PE can also be asymptomatic in patients with intrinsic tolerance of hypoxia. Patients with DVT may also present with swelling and pain of the respective extremity. The treatment of PE includes inpatient or outpatient anticoagulant therapy if the patient is hemodynamically unstable or stable, respectively. Hemodynamic instability may require transfer to the intensive care unit, and cardiovascular arrest can be implicated in fatal events. An important issue for patients with PE in the postoperative period after shoulder surgery is residual stiffness due to a delay in rehabilitation and a prolonged hospital stay. Early physiotherapy and range-of-motion exercises do not adversely affect the prognosis of PE and are highly recommended to preserve shoulder mobility and function.

Global trends and research hotspots in acupuncture treatment for cardiovascular diseases over the past decade: a bibliometric study

BACKGROUND

This study aims to examine the status and emerging trends of acupuncture treatment for cardiovascular disease (CVD) over the past decade. By conducting a visual analysis of existing literature, it seeks to offer new insights for future research directions.

METHODS

From the Web of Science Core Collection database, we retrieved papers on acupuncture treatment for CVD published between January 1, 2014, and December 31, 2023. Bibliometric analyses were conducted using VOSviewer and CiteSpace software to elucidate research progress and identify key research hotspots.

RESULTS

We identified 346 publications related to acupuncture for CVD that were published between 2014 and 2023. We determined the most productive journals, countries, institutions, authors, author patterns, and main directions for future research in the field of acupuncture. China was the top publishing country with 267 publications; Beijing University of Chinese Medicine was the leading institution with 42 publications; and the journal Evidence-Based Complementary and Alternative Medicine was the most prolific, with 43 publications. High-frequency keywords included "blood pressure," "acupuncture," "electroacupuncture," "stimulation," and "mechanism." The top five keywords by centrality ranking were "electroacupuncture," "myocardial ischemia," "stimulation," "randomized controlled trial," and "acupuncture."

CONCLUSION

While progress exists in bibliometric research on acupuncture treatment for CVD, more comprehensive analyses remain essential. This study provides a multidimensional overview, delineating current advancements and emerging trends, offering evidence-based insights for clinical practice and quantitative references for identifying collaborators, key institutions, and future directions.

Simultaneous bilateral total knee arthroplasty has higher risk of asymptomatic deep vein thrombosis in patients in their 80s compared with unilateral total knee arthroplasty: a propensity score-matched comparative study across different age groups

INTRODUCTION

This study compared complications and clinical outcomes between simultaneous bilateral total knee arthroplasty (SBTKA) and unilateral total knee arthroplasty (UTKA) across different age groups.

MATERIALS AND METHODS

This retrospective single-center study included 939 consecutive patients aged 60-89 years who underwent primary total knee arthroplasty between 2019 and 2023. After applying propensity score matching for preoperative deep vein thrombosis (DVT), American Society of Anesthesiologists (ASA) classification, and preoperative functional activity according to the Knee Society Score 2011 (KSS) to 223 patients who underwent SBTKA and 716 patients who underwent UTKA, SBTKA and UTKA were compared in the following age groups: 60s (28 vs. 28), 70s (110 vs. 110), and 80s (60 vs. 60). Perioperative complications and clinical outcomes at 1 year after surgery were compared between SBTKA and UTKA. Lower limb Doppler ultrasound was performed to screen for asymptomatic DVT preoperatively and on postoperative day 7.

RESULTS

Average ASA classification ranged from 2.0 to 2.2 across all age groups, with no difference between SBTKA and UTKA. Compared with UTKA, the decrease in hemoglobin was significantly greater after SBTKA in patients in their 70s and 80s (both p < 0.001). The proportion of blood transfusion showed no significant difference across all age groups. Asymptomatic DVT was more frequent after SBTKA than after UTKA in patients in their 80s (58.3% vs. 40.0%, p < 0.045), but not those in their 60s (42.9% vs. 32.1%) or 70s (50.9% vs. 46.3%). Clinical outcomes (knee symptoms, patient satisfaction, patient expectations, functional activity according to the KSS) were comparable between SBTKA and UTKA across all age groups at 1 year postoperatively.

CONCLUSIONS

SBTKA had higher risk of asymptomatic DVT in patients in their 80s. With evaluation of risk factors and careful patient selection, SBTKA is a valid option in terms of safety and clinical outcomes in elderly patients with ASA 2.

Pulmonary Embolism in Patients with End-Stage Kidney Disease Starting Dialysis

This cohort study examines the incidence and outcomes of pulmonary embolism as well as anticoagulant use among patients with end-stage kidney disease initiating dialysis.

Value of clinical review for AI-guided deep vein thrombosis diagnosis with ultrasound imaging by non-expert operators

Deep vein thrombosis (DVT) carries high morbidity, mortality, and costs globally. Point of care ultrasound (POCUS) image acquisition by non-ultrasound-trained providers, supported by an AI-based guidance and remote image review system, is believed to improve the timeliness and cost-effectiveness of diagnosis. We examine a database of 381 patients with suspected DVT who underwent an AI-guided ultrasound scan by a non-ultrasound-trained nurse and an expert sonographer-performed standard compression ultrasound scan. Each AI-guided scan was reviewed remotely by blinded radiologists or blinded independent POCUS-certified American Emergency Medicine (EM) physicians. Remote reviewer and standard scan diagnoses were compared. The primary endpoint is AI-guidance system sensitivity with clinician review; secondary endpoints include specificity, positive predictive value, negative predictive value, image quality, inter-observer image quality, and vein compressibility agreement. Data was analysed through the bootstrapping method, bootstrapping with a second reader for each scan, and a majority voting system. Eighty percent (n = 304) of scans were of sufficient diagnostic quality. Radiologist reviewer sensitivity ranged from 90%-95%, specificity from 74%-84%, NPV from 98%-99%, PPV from 30%-42%, and potential expert-led ultrasound scans avoided from 39%-50%. Inter-observer agreement for image quality was 0.15 and for compressibility 0.61. EM reviewer sensitivity ranged from 95%-98%, specificity from 97%-100%, NPV was 99%, PPV from 81%-100%, and potential expert-led ultrasound scans avoided from 29%-38%. Inter-observer agreement for image quality was 0.59 and for compressibility 0.67. Diagnosing lower extremity DVT through AI-guided image acquisition with clinician review is feasible. Performance is influenced by reviewer expertise. We find potential positive impacts on health economics, including safely avoiding expert-led ultrasound scans.

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.

Emerging Elastic Micro-Nano Materials for Diagnosis and Treatment of Thrombosis

Thrombus is a blood clot that forms in a blood vessel at the point of flaking. Thrombosis is closely associated with cardiovascular diseases caused by different sources and factors. However, the current clinical methods of thrombus diagnosis and treatment still have problems with targeting, permeability, stability, and biosafety. Therefore, in recent years, based on the development of micro/nano technology, researchers have tried to develop some new strategies for the diagnosis and treatment of thrombosis. Due to the unique structural characteristics, the micro-nano materials in physiological environments show excellent transport and delivery properties such as better in vivo circulation, longer life span, better targeting ability, and controllable cellular internalization. Especially, elasticity and stiffness are inherent mechanical properties of some well-designed micro-nano materials, which can make them better adapted to the needs of thrombosis diagnosis and treatment. Herein, this review first introduces the thrombotic microenvironment to characterize the thrombus development process. Then, to fine-tune the pathological occurrence and development of thrombosis, the role of elastic micro-nano materials for thrombus diagnosis and treatment is summarized. The properties, preparation methods, and biological fate of these materials have been discussed in detail. Following, the applications of elastic micro-nano materials in biomedical imaging, drug delivery, and therapy of thrombosis are highlighted. Last, the shortcomings and future design strategies of elastic micro-nano materials in diagnosis and treatment of clinical thrombosis are discussed. This review will provide new ideas for the use of nanotechnology in clinical diagnosis and treatment of thrombus in the future.

Venous thrombosis related to duplicated inferior vena cava: A case report and systematic review

RATIONALE

Swollen legs are commonly observed in clinical practice, and deep vein thrombosis (DVT) is 1 of the causes. Duplicated IVC (DIVC) is a relatively rare anomaly that results in DVT.

PATIENT CONCERNS

A 52-year-old male patient presented to the emergency department because of right leg swelling, pain, and redness for 3 days. His right leg was swollen from the sole to the thigh, with mild tenderness and local heat, without pitting edema.

DIAGNOSES

Laboratory tests showed mild elevated C-reactive protein (CRP) 3.82 mg/dL (reference value: 0-0.79 mg/dL), and notably high levels of D-dimer (25,700 ng/mL; reference value: 0-653). Lower limb computed tomography angiography showed duplication of the IVC (DIVC) and was highly suspicious for venous thrombosis involving the right popliteal vein, superficial femoral vein, common femoral vein, external iliac vein, internal iliac vein, common iliac vein, and inferior vena cava (IVC).

INTERVENTIONS

Enoxaparin (80 mg) was administered subcutaneously, twice daily. After admission, catheter-directed thrombolysis and thrombectomy via the right superficial femoral and popliteal veins were performed.

OUTCOMES

The congestion in the right lower leg improved, and the patient was discharged with rivaroxaban 15 mg twice daily 3 days later.

LESSONS

A systematic review using the keywords "duplication IVC," "thrombosis" and "case report" was performed on PubMed until May 2023. Males accounted for 55.2% (16 of 29) of the cohort. The mean ± standard deviation age of the patients was 48.9 ± 17.9 years old. Pulmonary embolism was documented in 27.6% (8 29) of the cases. Regarding treatments, we found that 21 patients (72.4%) used anticoagulants, 20 patients (69.0%) received IVC filter placement, and 7 cases (24.1%) were treated by catheter-directed thrombolysis. Women had a higher proportion of popliteal vein and calf vein thrombosis, with a statistically significant difference (25% vs 61.5%, P = .047 < .05), (12.5% vs 53.8%, P = .017 < .05). The incidence of DIVC is around 0.3% to 0.7% with male predominance. A DIVC is a risk factor for DVT, especially in young people.

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.

Effect of different balloon pressure band compression regimens on thrombolysis and lower limb venous blood flow velocity in patients undergoing anterograde thrombolysis via the superficial dorsalis pedis vein

OBJECTIVE

To evaluate the comparative effectiveness of two distinct balloon pressure band compression regimens on the treatment outcomes for deep vein thrombosis (DVT) and venous blood flow velocity in the lower limbs of patients undergoing anterograde thrombolysis through the superficial dorsalis pedis vein.

METHODS

A total of 42 patients diagnosed with DVT were enrolled in the randomized controlled trial. Patients in the control group received balloon pressure band compression positioned 15 cm above the bony landmark of the medial malleolus of the affected limb, with continuous inflation and deflation. On the basis of the control group, a balloon pressure band was also used 15 cm above the bony landmark of the medial malleolus and 10 cm below the midpoint of the patella in the affected limb in experimental group, with rotational inflation at these two sites. The thrombolysis effects and venous blood flow velocity of the lower extremities were compared between the two groups.

RESULTS

The differences in limb circumference and Marder scores of patients in the experimental group were significantly lower than those in the control group, while the detumescence rate and venous patency rate of the affected limbs in the experimental group were significantly higher than those in the control group (P < 0.05). After 30 and 60 min of thrombolysis, femoral and popliteal vein blood flow velocities in the experimental group were significantly higher than those in the control group (P < 0.05). After 45 min post-thrombolysis, the femoral vein blood flow velocity in the experimental group remained significantly higher than that in the control group (P < 0.05), though no significant difference was observed in the popliteal vein blood flow velocity (P > 0.05).

CONCLUSION

In this study, alternating balloon pressure band compression applied at 15 cm above the bony marker of the medial malleolus and 10 cm below the patellar midpoint to block superficial venous blood flow was found to enhance thrombolysis efficacy and significantly improve venous blood flow velocity in the lower extremities among patients with DVT.

Forensic considerations in nonthrombotic pulmonary embolism: A case report and review

Nonthrombotic pulmonary embolism is defined as the partial or total occlusion of the pulmonary circulation by various nonthrombotic agents, such as biological, nonbiological and foreign body material. A case is reported of lethal embolism of fragments of a renal calculus: A 64-year-old woman collapsed and died following laser lithotripsy. At autopsy calculous debris was found in the calyces of the right kidney with widespread microscopic fragments of birefringent foreign material in keeping with renal calculus within the pulmonary arterioles. Death was due to pulmonary calculus embolism complicating lithotripsy of a right renal calculus. Review of other causes of nonthrombotic pulmonary embolism revealed fat, bone marrow, amniotic fluid, trophoblast, tumours, septic material, hydatid cysts, bone, soft tissue/organ parenchyma, gastrointestinal tract contents/bile, gas, and foreign material that was introduced iatrogenically and non-iatrogenically. All of these possibilities should be considered at autopsy in the appropriate setting, with pulmonary microscopy often being essential to establishing the diagnosis.

How to explain the beneficial effects of platelet-rich plasma

Platelet-rich plasma (PRP) is the platelet and leukocyte-containing plasmatic fraction of anticoagulated autologous blood. While evidence supporting the clinical use of PRP in dentistry is low, PRP is widely used in sports medicine, orthopedics, and dermatology. Its beneficial activity is commonly attributed to the growth factors released from platelets accumulating in PRP; however, evidence is indirect and not comprehensive. There is thus a demand to revisit PRP with respect to basic and translational science. This review is to (i) recapitulate protocols and tools to prepare PRP; (ii) to discuss the cellular and molecular composition of PRP with a focus on platelets, leukocytes, and the fibrin-rich extracellular matrix of coagulated plasma; and finally (iii) to discuss potential beneficial effects of PRP on a cellular and molecular level with an outlook on its current use in dentistry and other medical fields.

External validation of a prognostic score to identify low-risk outpatients with acute deep venous thrombosis in the lower limbs

BACKGROUND

Current clinical guidelines suggest home treatment for patients diagnosed with acute deep venous thrombosis (DVT). A prognostic score has been proposed to identify low-risk patients; however, its validation remains limited.

METHOD

This prospective observational study aimed to externally validate the prognostic score in selecting low-risk outpatients with acute DVT in the lower limbs. Consecutive outpatients diagnosed with acute DVT in a tertiary hospital were included. The score included 6 variables: heart failure, kidney failure, recent major bleeding, altered platelet count, immobilization, and cancer. The primary outcome was the incidence of a composite outcome, including confirmed diagnosis of PE, major bleeding, or all-cause death at 7 days. Patients meeting zero criteria were considered low risk.

RESULTS

Among the 1035 patients included, 485 (46.9 %) met zero criteria. Of these, 0.2 % (95 % CI 0.0-1.1 %) and 0.4 % (95 % CI, 0.0-1.5 %) patients experienced the composite outcome at 7 and 30 days, respectively. Among patients who met 1 or more criteria for admission, 344 patients (62.5 %) were discharged. Among these, the composite outcome at 7 and 30 days occurred in 2 (0.6 %) and 5 (1.4 %) patients, respectively. The C-statistics of the score were 0.68 (95 % CI, 0.57-0.79) and 0.69 (95 % CI, 0.64-0.76) at 7 and 30 days, respectively.

CONCLUSION

This study demonstrates the efficacy of the prognostic score in identifying low-risk outpatients with acute DVT. It also suggests that a considerable proportion of patients with acute DVT may benefit from outpatient treatment despite having some risk criteria, highlighting the potential for optimizing ambulatory care pathways.

Analysis of clinical characteristics in 1940 patients with acute pulmonary embolism

BACKGROUND

The clinical characteristics of acute pulmonary embolism (APE) according to mortality risk has been partly explored. Further research is required in light of the latest guide update on risk stratification for APE.

METHODS

We collected the data from hospitalized patients with APE. Patients were classified according to the 2019 European Society of Cardiology's (ESC) guidelines. The clinical traits between different risk stratification of APE was investigated.

RESULTS

A total of 1940 patients had APE. Patients who were stratified as high risk showed the highest frequency of both syncope (4.5 % vs 6.6 % vs 12.7 %; P = 0.002) and dyspnea (61.9 % vs 73.0 % vs 73.8 %, P = 0.007) when compared to the other two groups. The rates of deep venous thrombosis (DVT) were: 49.4 % in low-risk stratification, 63.2 % in intermediate-risk stratification, and 68.1 % in high-risk stratification, (Pfor trend = 0.001), while the proportion of low-risk stratification patients increased (2.5 %-13.3 %, Pfor trend<0.001).

CONCLUSION

In conclusion, clinical characteristics differ among pulmonary embolism patients with different risk stratification. Furthermore, the percentage of low-risk patients increased progressively while overall in-hospital death rates among APE patients gradually decreased.

Anticoagulants utilization in eight hospitals within the Luzhou region from 2019 to 2023

BACKGROUND

With the increasing utilization of anticoagulants, the selection of appropriate anticoagulants has emerged as a significant quandary. The objective of this study was to evaluate recent trend in the utilization and expenditure of anticoagulants within a specific region, aiming to provide valuable insights into the optimal choice of anticoagulants across other healthcare facilities.

METHODS

The utilization of anticoagulants was retrospectively analyzed. The data on anticoagulant utilizations in tertiary-care hospitals within a district were collected from January 2019 to December 2023. The expenditure, defined daily doses (DDDs), and defined daily cost (DDC) were calculated. The trends in the utilization and expenditure of anticoagulants were examined using linear regression analysis.

RESULTS

From 2019 to 2023, the DDDs of rivaroxaban demonstrated a significant annual increase in most hospitals (p < 0.05). Only a few hospitals exhibited a gradual rise in the consumption of low molecular weight heparin (LMWH) over the same period (p < 0.05). The trend of heparin sodium and warfarin varied across different hospitals. The implementation of the centralized procurement policy, however, resulted in a decline in the consumption of rivaroxaban and LMWH in 2021 and 2022 respectively. The DDC value of rivaroxaban experienced a substantial decrease over the past five years (p = 0.020), declining from 55.20 Chinese Yuan (CNY) in 2019 to 4.28 CNY in 2023. Conversely, there was a slight increase noted in the DDC of heparin sodium during this time frame (p = 0.042).

CONCLUSION

Over the past five years (2019-2023), there has been an increase in the utilization of rivaroxaban and LMWH. However, their expenditure has decreased. In addition, the utilization and expenditure of warfarin and heparin sodium remained relatively stable. The application prospects of rivaroxaban and LMWH are promising.

The value of thrombus markers applied in patients with respiratory failure

Background

This work assessed the value of novel thrombus markers-thrombin-antithrombin complex (TAT), plasmin-a2-plasmin inhibitor complex (PIC), thrombomodulin (TM), and tissue plasminogen activator-inhibitor complex (t-PAIC) applied in patients with respiratory failure (RF), including their role in predicting thrombus formation, evaluating prognosis, and assessing disease severity.

Methods

Eighty patients with RF were enrolled and categorized into mild (n = 10), moderate (n = 9), and severe (n = 71) groups based on disease severity. Meanwhile, patients were also classified into thrombus (n = 14) and non-thrombus (n = 76) groups based on the presence of thrombus. Furthermore, they were assigned into survival (n = 70) and death (n = 20) groups based on prognosis. Traditional coagulation indicators, thrombus markers, infection-related parameters, and respiratory-related indicators were compared among patients in different groups. This work explored the predictive effects of these indicators on the degree of respiratory failure, thrombus formation, and prognosis in various patient groups. Additionally, correlations of thrombus markers and traditional coagulation indicators to respiratory-related indicators and infectionrelated indicators were analyzed.

Results

Upon admission, levels of thrombin-antithrombin complex (TAT), plasmin-a2-plasmin inhibitor complex (PIC), and tissue plasminogen activator-inhibitor complex (t-PAIC) in the thrombus group were sharply higher in contrast to those in the non-thrombus group, showing obvious differences (P<0.05). Patients in the death group experienced remarkably elevated TAT, PIC, t-PAIC, thrombomodulin (TM), and to the survival group (P<0.05). In addition, high-sensitivity C-reactive protein (hs-CRP) in the death group was higher to that in the survival group (P<0.05). Platelet count (PLT) and procalcitonin (PCT) were sharply lower in the survival group (P<0.05). In groups of varying severity, PCT exhibited an elevated level in the severe, demonstrating great differences to the mild to moderate groups (P<0.05). Besides, TAT, PIC, TM, and t-PAIC showed higher sensitivity and accuracy in predicting severe RF, with higher specificity in predicting thrombus formation in RF patients. In correlation analysis, a positive correlation was observed between TT, PCT, and the fraction of inspired oxygen (FiO2). The activated partial thromboplastin time (APTT), PCT, and FiO2 exhibited positive correlations. Additionally, a positive association existed between fibrinogen (FIB), hs-CRP, and PLT. A positive link was identified between D-dimer and hs-CRP, PIC and PLT, as well as tPAIC and PCT.

Conclusions

Thrombus markers exerted a crucial effect in patients experiencing respiratory failure, serving as pivotal indicators for assessing the severity of the condition, identifying thrombotic risk, and predicting prognosis.

Association between inflammatory indices and preoperative deep vein thrombosis in patients undergoing total joint arthroplasty: a retrospective study

BACKGROUND

To investigate the association between inflammatory indices-systemic immune-inflammation index (SII), monocyte-lymphocyte ratio (MLR), neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and preoperative deep vein thrombosis (DVT) in patients undergoing total joint arthroplasty (TJA).

METHODS

We created the receiver operator characteristic (ROC) curve using the ratios of SII, MLR, NLR, PLR to DVT before TJA, divided the enrolled patients into groups based on the cut-off value, and then analyzed risk factors for DVT before TJA in the multivariate binary logistic regression analysis.

RESULTS

A total of 2125 patients were enrolled and preoperative DVT occurred in 110 cases (5.18%). Based on the ROC curve, we determined that the cut-off values for SII, MLR, NLR, and PLR were 470*109 /L, 0.306, 2.08, and 127; and the areas under the curve (AUC) were 0.623, 0.601, 0.611, and 0.62. Multivariate binary regression analysis revealed that the risk of preoperative DVT in TJA patients with SII ≥ 470*109/L, MLR ≥ 0.306, PLR ≥ 127, and NLR ≥ 2.08 increased by 2.26 (P < 0.001, 95% confidence interval (CI) [1.52-3.37]), 1.92 (P = 0.002, 95% CI [1.28-2.9]), 2.1 (P < 0.001, 95% CI [1.4-3.16]), and 1.94 (P = 0.002, 95% CI [1.29-2.92]) times, respectively. Age, P < 0.001, odds ratio (OR) = 1.08, 95%CI [1.05-1.10]; corticosteroid use, P = 0.002, OR 3.8, 95% CI [1.94-9.22]).

CONCLUSION

We found that higher SII, MLR, NLR, and PLR levels, age, and corticosteroid use were independent risk factors for preoperative DVT in patients undergoing TJA.

CLINICAL TRIAL REGISTRATION

ChiCTR2100054844; Registration Date: 2021.12.28.

Lymphatic platelet thrombosis limits bone repair by precluding lymphatic transporting DAMPs

In the musculoskeletal system, lymphatic vessels (LVs), which are interdigitated with blood vessels, travel and form an extensive transport network. Blood vessels in bone regulate osteogenesis and hematopoiesis, however, whether LVs in bone affect fracture healing is unclear. Here, we investigate the lymphatic draining function at the tibial fracture sites using near-infrared indocyanine green lymphatic imaging (NIR-ICG) and discover that lymphatic drainage insufficiency (LDI) starts on day one and persists for up to two weeks following the fracture in male mice. Sufficient lymphatic drainage facilitates fracture healing in male mice. Furthermore, we identify that lymphatic platelet thrombosis (LPT) blocks the draining lymphoid sinus and LVs, causes LDI, and inhibits fracture healing in male mice, which can be rescued by a blood thinner. Moreover, unblocked lymphatic drainage decreases neutrophils and increases M2-type macrophages of the hematoma niche to support osteoblast (OB) survival and bone marrow-derived mesenchymal stem cell (BMSC) proliferation via transporting damage-associated molecular patterns (DAMPs) in male rats. Lymphatic platelet thrombolysis also benefits senile fracture healing in female mice. These findings demonstrate that LPT limits bone regeneration by impeding lymphatic transporting DAMPs. Together, these findings represent a way forward in the treatment of bone repair.

Bleeding in patients hospitalized with acute pulmonary embolism in Brazil

OBJECTIVE

Acute Pulmonary Embolism (APE) is a disease with increasing incidence worldwide. Antithrombotics are the cornerstone of the treatment. Bleeding is an adverse event related to this therapy. The objective was to evaluate the prevalence of bleeding in a sample of Brazilian patients hospitalized with APE and the impact of this complication on mortality. Additionally, the performance of some bleeding predictive scores was evaluated in this sample.

METHODS

A retrospective cohort study was carried out on patients hospitalized with APE from January 2009 through August 2017. The medical records of these patients were reviewed, and the bleeding recorded during hospital stay was classified according to the "Thrombolysis in Myocardial Infarction (TIMI) bleeding risk." Five different predictive scores for bleeding after APE (RIETE, PE-SARD, VTE-BLEED, Kuijer, and ATRIA) were applied. Overall mortality at 30 days and one year were assessed.

RESULTS

One hundred fifty-nine patients were included. The prevalence of any bleeding was 36/159 (23 %), major bleeding was 10/159 (06 %), minor bleeding was 11/159 (07 %), and bleeding requiring attention was 15/159 (10 %). Only major bleeding was associated with higher mortality at one-year follow-up with a Relative Risk (RR) of 2.00 (95 % CI 1.16-3.57; p = 0.044). All bleeding predictive scores evaluated showed low accuracy in identifying patients at higher risk of bleeding.

CONCLUSION

Patients hospitalized with APE in Brazil had a high prevalence of bleeding. The major bleeding increased the one-year mortality. The bleeding predictive scores assessed showed limited accuracy in identifying patients at high risk of bleeding.

Prediction of pulmonary embolism by an explainable machine learning approach in the real world

In recent years, large amounts of researches showed that pulmonary embolism (PE) has become a common disease, and PE remains a clinical challenge because of its high mortality, high disability, high missed and high misdiagnosed rates. To address this, we employed an artificial intelligence-based machine learning algorithm (MLA) to construct a robust predictive model for PE. We retrospectively analyzed 1480 suspected PE patients hospitalized in West China Hospital of Sichuan University between May 2015 and April 2020. 126 features were screened and diverse MLAs were utilized to craft predictive models for PE. Area under the receiver operating characteristic curves (AUC) were used to evaluate their performance and SHapley Additive exPlanation (SHAP) values were utilized to elucidate the prediction model. Regarding the efficacy of the single model that most accurately predicted the outcome, RF demonstrated the highest efficacy in predicting outcomes, with an AUC of 0.776 (95% CI 0.774-0.778). The SHAP summary plot delineated the positive and negative effects of features attributed to the RF prediction model, including D-dimer, activated partial thromboplastin time (APTT), fibrin and fibrinogen degradation products (FFDP), platelet count, albumin, cholesterol, and sodium. Furthermore, the SHAP dependence plot illustrated the impact of individual features on the RF prediction model. Finally, the MLA based PE predicting model was designed as a web page that can be applied to the platform of clinical management. In this study, PE prediction model was successfully established and designed as a web page, facilitating the optimization of early diagnosis and timely treatment strategies to enhance PE patient outcomes.

S100 calcium-binding protein A8 exacerbates deep vein thrombosis in vascular endothelial cells

Previous studies highlighting the pivotal function of the S100A8 protein have shown that inflammation and vascular endothelial harm play a major role in deep vein thrombosis (DVT) development, as evidenced by earlier studies highlighting the pivotal function of the S100 calcium-binding protein A8 (S100A8). Therefore, we aimed to establish a connection between S100A8 and DVT and investigate the role of S100A8 in DVT development. Blood specimens were taken from 23 patients with DVT and 31 controls. The fluctuation and association for S100A8 and interleukin-1 beta (IL-1β) in the specimens was assessed using enzyme-linked immunosorbent assay. We also used the human recombinant protein S100A8 to activate human umbilical vein endothelial cells and created a rat model to explore the possible relationship between them. Studies have shown that the infiltration of S100A8 sustains local inflammation and thrombus formation, which may exacerbate DVT by amplifying NLRP3/Caspase-1/IL-1β signals in the vascular endothelial cells.

[Translated article] Thrombotic event prevention in patients undergoing posterior lumbar arthrodesis: Our experience. A retrospective case series study

INTRODUCTION

There is no generalised consensus regarding perioperative prophylaxis of venous thromboembolism (VTE), either on using or timing it in patients undergoing spine surgery. VTE is a current concern because, even though being an uncommon event, it can cause serious complications. The aim of the present study is to propose guidelines for the prevention of thrombotic events in posterior spinal surgery, either as deep vein thrombosis or pulmonary thromboembolism. If the number of patients getting prophylaxis drugs is reduced a subsequent reduction of the incidence of epidural haematoma can be expected.

MATERIALS AND METHODS

A number of 235 patients who had undergone posterior spinal arthrodesis in the previous five years were studied. Mechanical thromboprophylaxis measures consisting of compression stockings were applied in all of them. Anticoagulant drugs were also applied whenever risk factors for thrombosis were observed. Early weight-bearing was resumed immediately after surgery. Demographic, clinical, and surgical variables were collected, as well as complications appearing during the follow-up period, that was scheduled at one, two, four, six and twelve months after the surgery. Thrombotic events, if present, were diagnosed by clinical and imaging tests such as ultrasound and CT angiography.

RESULTS

From the total 235 patients of this series, one hundred and fifty-three cases met the study inclusion criteria. A total of four thrombotic events appeared, one in the form of deep vein thrombosis and other three in the form of pulmonary thromboembolism. These last patients suffering an embolism died because of it. None of the variables studied had statistical significance for the occurrence of a thrombotic event. All four patients who suffered thrombotic events were receiving anticoagulant drugs, in addition to mechanical compression stockings, because of the presence of risk factors for thrombosis.

CONCLUSIONS

By applying the fore mentioned protocol, adequate prevention of thromboembolic events was achieved in this study population of patients undergoing posterior spinal surgery.

Thrombotic Event Prevention in Patients Undergoing Posterior Lumbar Arthrodesis: our experiencie. A retrospective case series study

INTRODUCTION

There is no generalized consensus regarding perioperative prophylaxis of venous thromboembolism (VTE), either on using or timing it in patients undergoing spine surgery. VTE is a current concern because, even though being an uncommon event, it can cause serious complications. The aim of the present study is to propose guidelines for the prevention of thrombotic events in posterior spinal surgery, either as deep vein thrombosis or pulmonary thromboembolism. If the number of patients getting prophylaxis drugs is reduced a subsequent reduction of the incidence of epidural hematoma can be expected.

MATERIALS AND METHODS

A number of 235 patients who had undergone posterior spinal arthrodesis in the previous five years were studied. Mechanical thromboprophylaxis measures consisting of compression stockings were applied in all of them. Anticoagulant drugs were also applied whenever risk factors for thrombosis were observed. Early weight-bearing was resumed immediately after surgery. Demographic, clinical, and surgical variables were collected, as well as complications appearing during the follow-up period, that was scheduled at one, two, four, six and twelve months after the surgery. Thrombotic events, if present, were diagnosed by clinical and imaging tests such as ultrasound and CT angiography.

RESULTS

From the total 235 patients of this series, one hundred and fifty-three cases met the study inclusion criteria. A total of four thrombotic events appeared, one in the form of deep vein thrombosis and other three in the form of pulmonary thromboembolism. These last patients suffering an embolism died because of it. None of the variables studied had statistical significance for the occurrence of a thrombotic event. All four patients who suffered thrombotic events were receiving anticoagulant drugs, in addition to mechanical compression stockings, because of the presence of risk factors for thrombosis.

CONCLUSIONS

By applying the fore mentioned protocol, adequate prevention of thromboembolic events was achieved in this study population of patients undergoing posterior spinal surgery.

Clinical Characteristics and Outcomes of Deep Vein Thrombosis in Relation to Location: A Retrospective Analysis Study

Background: Deep vein thrombosis (DVT) is a leading cause of death disability. DVT can be classified based on the location and extent of the clot into isolated distal DVT (iDDVT), isolated proximal DVT (iPDVT), or mixed DVT. The aim of this study is to explore the baseline characteristics and clinical outcomes of patients with different types of DVT. Methods: This was a retrospective study of patients who experienced their first DVT event and received an anticoagulant for management. The outcomes of this study include evaluating patients' characteristics for patients with DVT and assessing the incidence of recurrent DVT, major bleeding (MB), VTE-related rehospitalization, and DVT-related inpatient mortality across different types of DVT. Results: A total of 493 patients were included in the study. Of those, 273 (55.4%) had iPDVT, 25 (5.1%) had iDDVT, and 195 (39.6%) had mixed DVT. The VTE etiology was similar across the groups except for the leg injury, which was significantly higher in patients with iDDVT (24%) compared to iPDVT (6.2%) and mixed DVT (5.6%) (P = .002). At 12 months, a total of 49 patients (9.9%) had a recurrent DVT event; 25 (9.2%) in the iPDVT group, 3 (12.0%) in the iDDVT group, and 21 (10.8%) in the mixed DVT group (P = .797). Rates of MB, re-hospitalization, and death from DVT were similar between the groups. Conclusion: Baseline characteristics were not significantly linked to the risk of developing a specific type of lower extremity DVT. Long-term outcomes were similar across all DVT types.

Poly (β-amino esters)/Mobil Composition of Matter 41-mediated delivery of siIL-1β alleviates deep vein thrombosis in rat hind limbs

Introduction: Deep vein thrombosis (DVT) is a major cause of cardiovascular disease-related deaths worldwide and is considered a thrombotic inflammatory disorder. IL-1β, as a key promoter of venous thrombus inflammation, is a potential target for DVT treatment. Constructing a nanocarrier system for intracellular delivery of siIL-1β to silence IL-1β may be an effective strategy for alleviating DVT. Methods: ELISA was used to detect the expression levels of IL-1β and t-PA in the serum of DVT patients and healthy individuals. In vitro, HUVEC cells were treated with IL-1β, and changes in VWF and t-PA expression levels were assessed. PBAE/MCM-41@siIL-1β (PM@siIL-1β) nano-complexes were synthesized, the characterization and biocompatibility of PM@siIL-1β were evaluated. A rat hind limb DVT model was established, and PM@siIL-1β was used to treat DVT rats. Morphology of the inferior vena cava, endothelial cell count, IL-1β, vWF, and t-PA levels, as well as changes in the p38 MAPK and NF-κB pathways, were examined in the different groups. Results: IL-1β and t-PA were highly expressed in DVT patients, and IL-1β treatment induced a decrease in VWF levels and an increase in t-PA levels in HUVEC cells. The synthesized PM@siIL-1β exhibited spherical shape, good stability, high encapsulation efficiency, and high drug loading capacity, with excellent biocompatibility. In the DVT model rats, the inferior vena cava was filled with blood clots, endothelial cells increased, IL-1β and VWF levels significantly increased, while t-PA levels were significantly downregulated. Treatment with PM@siIL-1β resulted in reduced thrombus formation, decreased endothelial cell count, and reversal of IL-1β, VWF, and t-PA levels. Furthermore, PM@siIL-1β treatment significantly inhibited p38 phosphorylation and upregulation of NF-κB expression in the DVT model group. Conclusion: IL-1β can be considered a therapeutic target for suppressing DVT inflammation. The synthesized PM@siIL-1β achieved efficient delivery and gene silencing of siIL-1β, demonstrating good therapeutic effects on rat hind limb DVT, including anti-thrombotic and anti-inflammatory effects, potentially mediated through the p38 MAPK and NF-κB pathways.

Relationship between high levels of D-dimer and prognosis in patients with spontaneous supratentorial cerebral haemorrhage: A retrospective study and double validation

OBJECTIVE

The aim of this study was to investigate the correlation between D-Dimer and unfavorable outcome after surgery for spontaneous supratentorial intracerebral hemorrhage(SSICH) METHODS: A total of 557 patients with spontaneous supratentorial intracerebral hemorrhage underwent surgical treatment, which included craniotomy evacuation of hematoma and puncture and drainage. Based on the modified Rankin Scale (mRS) bifurcation, the patients were divided into two subgroups: favorable outcome (mRS score 0-2) and unfavorable outcome (mRS score 3-5). D-dimer levels were measured within 24 h of admission, monitored until discharge, and grouped by quartiles (Q1-Q4). We collected and calculated D-dimer levels at different periods of time: (1) at admission (pre-surgery); (2) average post-surgery level; (3) average level during hospitalization; and (4) peak level during hospitalization. Two methods were used for validation, the first using a traditional multifactorial Logsitic regression equation, and the second where we chose baseline clinical, laboratory, and other variables and constructed a prognostic model through multivariate logistic regression.

RESULTS

Statistical results showed statistically significant differences in age, Glasgow Coma Score (GCS) on admission, high levels of D-dimer, and bleeding. Predictive models developed on the basis of initial age, GCS, and D-Dimer showed good discriminatory power CONCLUSIONS: D-dimer is an independent risk factor for the development of poor postoperative prognosis in patients with SSTICH, and a prognostic model developed on the basis of D-Dimer predicts the development of poor postoperative prognosis in patients with SSTICH. The model needs to be validated in larger studies conducted at other institutions.

Diagnostic value of systematic compression ultrasonography for the detection of unrecognized venous thromboembolism in patients admitted to an internal medicine ward for dyspnea

The diagnosis of venous thromboembolism (VTE) is complex, and many cases of pulmonary embolism (PE) and deep vein thrombosis (DVT) go undetected despite validated diagnostic algorithms. This study evaluated the diagnostic performance of compression ultrasound (CUS) when systematically performed in patients admitted to an internal medicine department for dyspnea and/or respiratory failure. We conducted a prospective observational cohort study of consecutive adult hospitalized patients admitted for dyspnea and/or respiratory failure with at least one of the following: tachycardia (> 100 bpm), tachypnea (> 20/min), chest pain, cough, syncope, or hemoptysis. Patients with a previous diagnosis of VTE or who underwent computed tomography pulmonary angiography (CTPA) or CUS during evaluation in the emergency department were excluded. The study included 263 patients (50.2% women, average age 84 years). CUS was positive in 31 patients (11.8%); Bilateral DVT was diagnosed in two patients and unilateral DVT in 29 patients. Of these, 10 underwent CT scan, with PE confirmed in 9 cases. Using the Wells score for DVT (cut-off ≥ 2), only 8 patients (25.8%) were at high risk. The accuracy of the Wells score in identifying PE was suboptimal, as 5 of 9 patients (55.5%) with confirmed PE were in the low-risk group (three-level interpretation) and 8 (89.9%) were in the "EP unlikely" group (two-level interpretation). The systematic use of CUS as a point-of-care tool can improve the diagnostic accuracy for VTE in patients admitted to internal medicine departments with dyspnea/respiratory failure.

Advanced Management of Patients Undergoing Transcatheter Treatment for Pulmonary Embolism: Evidence-Based Strategies for Optimized Patient Care

Pulmonary embolism (PE) is a life-threatening medical condition caused by the thrombotic occlusion of one or more branches of the lung vasculature, which represents the third most common cause of cardiovascular mortality after myocardial infarction and stroke. PE treatment requires a tailored approach based on accurate risk stratification and personalized treatment decision-making. Anticoagulation is the cornerstone of PE management, yet patients at higher clinical risk may require more rapid reperfusion therapies. In recent years, transcatheter treatment has emerged as a valuable option for patients with intermediate-high or high-risk PE who have contraindications to systemic thrombolysis. Recent advancements in catheter-directed therapies, such as catheter-directed thrombolysis (CDT) and catheter-directed mechanical thrombectomy (CDMT), provide minimally invasive options for swift symptom relief and hemodynamic stabilization. This review aims to provide a practical approach for optimal patient selection and management for PE percutaneous therapies, supported by a thorough evaluation of the current evidence base supporting these procedures. A focus on post-procedural management, the prevention of recurrence, and monitoring for long-term complications such as chronic pulmonary hypertension and post-PE syndrome is also specifically tackled.

Deep learning model for diagnosis of venous thrombosis from lower extremity peripheral ultrasound imaging

Deep vein thrombosis (DVT) causes significant healthcare burdens worldwide. This study aims to establish a deep learning model for the diagnosis of DVT from the assessment of vein compressibility. Considering the complexity of ultrasound images, convolutional neural networks with UNet and residual neural network (ResNet) are established for image segmentation, from venous duplex ultrasonographic video images, obtained through standard and portable handheld ultrasound methods. To further evaluate the similarity between the predicted and ground truth images, the structural similarity index (SSIM) is employed. Our deep learning model achieves over 90% accuracy, providing an innovative tool for both images and videos. This study harnesses the power of machine learning to develop an automatic labeling tool that can diagnose DVT by analyzing ultrasonography images. To make the tool more accessible to front-line clinicians, a user-friendly application is created to quickly assess possible clinical severity and enable prompt medical intervention, reducing disease progression.

Analysis of risk factors and establishment of prediction model for lower extremity deep vein thrombosis after lumbar fusion surgery

BACKGROUND

Lower extremity deep vein thrombosis (LEDVT) is a common complication after orthopedic surgery. Currently, a reliable assessment tool is lacking to evaluate the risk of postoperative LEDVT in patients undergoing lumbar fusion surgery. This study aims to explore the risk factors for LEDVT formation after lumbar fusion surgery and establish a predictive model for it.

METHODS

Data of patients admitted for multi-center spinal surgery from May 2022 to September 2023 were retrospectively collected. Patients were divided into DVT and non-DVT groups based on the occurrence of LEDVT after surgery. Potential risk factors were initially identified through intergroup comparative analysis and single-factor logistic regression, which were considered candidate indicators. LASSO regression was applied to select candidate indicators, and the filtered variables were included in a multivariable logistic regression model. Nomogram and dynamic nomogram were constructed to visualize the model, and the model was subsequently validated.

RESULTS

Factors including weakened lower extremity muscle strength, intraoperative blood loss, walking impairment, and Venous reflux/ Varicose veins were included in the multivariable logistic regression model. The results showed that the model had an area under the receiver operating characteristic curve of 0.870, 0.777 and 0.750 for the training set, internal validation set, and external validation set, respectively. Nomograms and web-based dynamic nomograms were created based on the multivariable logistic regression model. The model exhibited good performance in calibration curves and decision analysis.

CONCLUSION

The study identified weakened lower extremity muscle strength, intraoperative blood loss, walking impairment, and Venous reflux/ Varicose veins as risk factors for LEDVT formation following lumbar fusion surgery. The predictive tool established based on the logistic regression model demonstrated good performance and can be considered for assessing the risk of LEDVT formation after lumbar fusion surgery.

Association of thromboelastogram hypercoagulability with postoperative deep venous thrombosis of the lower extremity in patients with femur and pelvic fractures: a cohort study

BACKGROUND

The relationship between thromboelastogram (TEG) hypercoagulation status and perioperative deep vein thrombosis (DVT) in patients with femoral and pelvic fractures is not well understood. We aimed to investigate the relationship between hypercoagulation status identified by thromboelastography and postoperative DVT formation in patients with femoral and pelvic fractures, as well as to evaluate the role of thromboelastography in assessing hypercoagulation status and predicting postoperative DVT formation.

METHODS

Data from 2,065 patients with femoral and pelvic fractures who underwent surgical treatment at a hospital in China between May 2018 and December 2023 were retrospectively analysed. Hypercoagulable TEG was defined as reaction time (R) < 5 min, coagulation time (K) < 1 min, alpha angle (α) > 72 degrees, maximum amplitude (MA) > 70 mm, and/or coagulation index (CI) > 3. The correlation between preoperative hypercoagulability identified by TEG and postoperative DVT formation was assessed using multivariate logistic regression. Propensity score matching (PSM) was performed to control for confounding factors.

RESULTS

Compared to the non-DVT group, the DVT group had decreased R and K values, while the α, MA, and CI values significantly increased (P < 0.05). Multivariate logistic regression analysis demonstrated that hypercoagulable TEG findings were predictive of postoperative DVT formation. PSM, using a 0.1 calliper value, matched 296 patients from the hypercoagulation and non-hypercoagulation groups in a 1:1 ratio. Before PSM, hypercoagulable TEG was associated with DVT in femoral and pelvic fractures (P < 0.001, odds ratio [OR]:1.860, 95% confidence interval: 1.389-2.492). After PSM, these two variables remained correlated (P = 0.001, OR = 1.878, 95% confidence interval:1.301 - 2.709).

CONCLUSIONS

The hypercoagulable state identified by TEG can predict thromboembolic events in patients with femoral and pelvic fractures.

TRIAL REGISTRATION

The study was registered in the Chinese Clinical Trial Register ( https://www.chictr.org.cn/bin/home ) on April 16, 2024, with registration number ChiCTR2400083135.

The time-dependent expression of FPR2 and ANXA1 in murine deep vein thrombosis model and its relation to thrombus age

Thrombus age determination in fatal venous thromboembolism cases is an important task for forensic pathologists. In this study, we investigated the time-dependent expressions of formyl peptide receptor 2 (FPR2) and Annexin A1 (ANXA1) in a stasis-induced deep vein thrombosis (DVT) murine model, with the aim of obtaining useful information for thrombus age timing. A total of 75 ICR mice were randomly classified into thrombosis group and control group. In thrombosis group, a DVT model was established by ligating the inferior vena cava (IVC) of mice, and thrombosed IVCs were harvested at 1, 3, 5, 7, 10, 14, and 21 days after modeling. In control group, IVCs without thrombosis were taken as control samples. The expressions of FPR2 and ANXA1 during thrombosis were detected using immunohistochemistry and double immunofluorescence staining. Their protein and mRNA levels in the samples were determined by Western blotting and quantitative real-time PCR. The results reveal that FPR2 was predominantly expressed by intrathrombotic neutrophils and macrophages. ANXA1 expression in the thrombi was mainly distributed in neutrophils, endothelial cells of neovessels, and fibroblastic cells. After thrombosis, the expressions of FPR2 and ANXA1 were time-dependently up-regulated. The percentage of FPR2-positive cells and the level of FPR2 protein significantly elevated at 1, 3, 5 and 7 days after IVC ligation as compared to those at 10, 14 and 21 days after ligation (p < 0.05). Moreover, the mRNA level of FPR2 were significantly higher at 5 days than that at the other post-ligation intervals (p < 0.05). Besides, the levels of ANXA1 mRNA and protein peaked at 10 and 14 days after ligation, respectively. A significant increase in the mRNA level of ANXA1 was found at 10 and 14 days as compared with that at the other post-ligation intervals (p < 0.01). Our findings suggest that FPR2 and ANXA1 are promising as useful markers for age estimation of venous thrombi.

MicroRNA-181b-5p/HEY2 axis is involved in the progress of deep venous thrombosis via mediating vascular endothelial injury

OBJECTIVES

Deep-venous thrombosis (DVT) refers to abnormal blood clotting in the deep vein cavity, and post-thrombotic syndrome (PTS) is the most frequent complication. The study explored the impact of microRNA 181b-5p on DVT progression based on human umbilical vein endothelial cells (HUVECs).

METHODS

Levels of miR-181b-5p were examined in 150 cases with acute lower extremity DVT. ROC curve and K-M plot were drawn for clinical value assessment. The role of miR-181b-5p in HUVECs viability, migration, apoptosis, inflammatory response and adhesion factors' release was investigated. Target gene of miR-181b-5p was predicted, and its role in cell function was explored.

RESULTS

Low-expressed miR-181b-5p showed favorable diagnostic performance in differentiating DVT with the AUC of 0.948. Patients with low miR-181b-5p had a high incidence of PTS. miR-181b-5p overexpression promoted HUVECs' viability and migration, while inhibiting cell apoptosis and release of inflammatory and adhesion cytokines. As the target gene of miR-181b-5p, HEY2 overexpression reversed the role of miR-181b-5p in HUVECs.

CONCLUSION

MiR-181b-5p serves as a potential biomarker for DVT diagnosis and PTS development. Overexpression of this miRNA targeted HEY2 to alleviate endothelial cell damage.

Clinical features, outcomes, and anticoagulant strategies in lung cancer-associated isolated distal deep vein thrombosis

INTRODUCTION

The clinical presentation, outcomes, and anticoagulation strategies in patients with lung cancer-associated isolated distal deep vein thrombosis (LC-iDDVT) are not well-defined.

MATERIALS AND METHODS

The study included 593 patients with LC-iDDVT and 260 patients with lung cancer-associated proximal DVT (LC-Proximal DVT). LC-iDDVT was further classified into axial venous thrombosis (AVT; 112 patients) and muscular venous thrombosis (MVT; 481 patients). Cox proportional risk regression models with Fine-Gray tests and competing risk models were employed to evaluate short-term (90-day) and long-term (1-year) outcomes (hazard ratio [HR]; 95 % confidence intervals [CI]).

RESULTS

At the 90-day follow-up, patients with MVT had lower adjusted risks of pulmonary embolism (PE; HR = 0.20 [0.07-0.55], p = 0.002) and venous thromboembolism (VTE) recurrence (HR = 0.54 [0.34-0.88], p = 0.013) than those with LC-Proximal DVT. Similar results were observed at the 1-year follow-up. However, adjusted risks for PE (HR = 0.74 [0.29-1.92], p = 0.540; HR = 0.87 [0.42-1.78], p = 0.700) and VTE recurrence (HR = 0.96 (0.54-1.71), p = 0.890; HR = 0.99 [0.63-1.56], p = 0.970) at 90-day and 1-year were not significantly different between patients with AVT and those with LC-Proximal DVT. Among patients with LC-iDDVT, those receiving anticoagulation had reduced risks of VTE recurrence (HR = 0.57 [0.35-0.95], p = 0.030) and DVT deterioration (HR = 0.28 [0.13-0.60], p = 0.001) compared to those without anticoagulation. Moreover, AVT patients on >3 months of anticoagulation had a lower VTE recurrence risk (HR = 0.23 [0.03-0.92], p = 0.038) than those on ≤3 months of anticoagulation.

CONCLUSION

In the context of lung cancer, patients with AVT may have a higher tendency for recurrent thrombosis compared to those with MVT, especially if anticoagulation is refused or given briefly.