Second consensus document on diagnosis and management of acute deep vein thrombosis: updated document elaborated by the ESC Working Group on aorta and peripheral vascular diseases and the ESC Working Group on pulmonary circulation and right ventricular function

The calf muscle strength correlation with the severity of ischemia and outcomes in patients with chronic lower limb ischemia

OBJECTIVE

The association between peripheral arterial disease (PAD) as one of the chronic vascular diseases with decreased muscle endurance of the lower limbs has been reported in many studies. This study evaluated the correlation between calf strength measures with disease severity and its outcomes in patients with chronic limb ischemia.

PARTICIPANTS

This study was conducted on 53 patients with chronic limb ischemia referred to the Department of Vascular Surgery Taleghani Hospital, affiliated to Shahid Beheshti University of Medical Sciences between October 2020 and November 2021.

DESIGN

The strength measurements included the dorsiflexion strength (DFS) and plantar flexion strength (PFS) of the affected limbs, which were measured using a newly developed dynamometer. Disease severity evaluated with angiography and outcomes were evaluated in all patients for three months.

RESULTS

The mean age was 64.51 ± 9.3 years. The mean DFS and PFS were 13.55 ± 4.24 kg and 20.1 ± 8.29 kg, respectively. The need for invasive intervention was required in 42 (79.2%) patients. Amputation was performed in 21(39.6%). The multivariate analysis showed chronic limb ischemia severity (B: 7.11, 95% CI: 11.74, -2.46, P: 0.001), involvement level (B: 2.53, 95% CI: 4.03, -1.02, P: 0.042) and outcome type (B: 2.66, 95%CI: 4.22, -1.08, P: 0.039) were significantly related to DFS. The chronic limb ischemia severity (B: 3.89, 95%CI: 6.14, -1.64, P: 0.002) and level of involvement (B: 2.11, 95%CI: 3, -1.01, P:0.047) were significantly associated with PFS.

CONCLUSION

Our study showed that PFS and DFS were lower in patients with severe forms of chronic limb ischemia and those with simultaneous involvement of both above and below knee. DFS in patients requiring amputation was significantly lower than patients who did not require amputation during three months follow-up.

Benefit-Risk Assessment of Rivaroxaban in Older Patients With Nonvalvular Atrial Fibrillation or Venous Thromboembolism

BACKGROUND

Both bleeding and adverse ischemic events increase with age, compounding the benefit-risk balance of anticoagulants in older patients. We present analyses using benefit-risk methods to better understand the age-dependence of the benefit-risk profile of rivaroxaban in patients with nonvalvular atrial fibrillation (NVAF) or venous thromboembolism (VTE).

METHODS

Randomized controlled trial data from the ROCKET-AF (NVAF) and EINSTEIN DVT, EINSTEIN PE, EINSTEIN-Extension, and EINSTEIN CHOICE in (VTE) were used. For ROCKET-AF, benefits and risks were assessed with incidence rates for key thrombotic and bleeding endpoints and a net clinical benefit (NCB) measure. Cumulative incidences (estimated by the Kaplan-Meier method) were estimated at day 185 for EINSTEIN and EINSTEIN Extension and 1 year for EINSTEIN CHOICE. Incidence differences were calculated for the overall population and age subgroups of < 65, 65-75, and > 75 years.

RESULTS

In ROCKET-AF, rate differences in the composite NCB outcome (vascular death, stroke, myocardial infarction, fatal bleeding, critical organ bleeding, and non-CNS systemic embolism) favored rivaroxaban overall and by age < 65, 65-75, and > 75 years (-84, -25, -61, and -150 cases per 10,000 patient-years, respectively). In the pooled EINSTEIN DVT and EINSTEIN PE studies, cumulative incidence differences for the composite NCB outcome (recurrent VTE and major bleeding) were -103, 3, -105, and -544 per 10,000 patients, respectively. For extended VTE treatment with rivaroxaban versus placebo in EINSTEIN-Extension, NCB results were -536, -492, -556, and -601 per 10,000 patients, respectively. In the EINSTEIN CHOICE analysis, NCB favored rivaroxaban 20 mg versus aspirin (-284, -255, -339, and -338, respectively) and rivaroxaban 10 mg versus aspirin (-339, -328, -485, and -80, respectively).

CONCLUSIONS

This analysis demonstrated a positive benefit-risk profile with rivaroxaban versus trial comparators in older patients with NVAF or VTE, with benefit-risk increasingly favoring rivaroxaban with increasing age.

CLINICAL TRIAL REGISTRATION

http://ClinicalTrials.gov , identifiers: NCT00403767 (ROCKET-AF), NCT00440193 (EINSTEIN DVT), NCT00439777 (EINSTEIN PE), NCT00439725 (EINSTEIN Extension), and NCT02064439 (EINSTEIN CHOICE).

Therapeutic applications of natural products in the management of venous diseases: a comprehensive review

The occurrence of venous diseases among adults is approximately 77% in females and 57% in males. These conditions are prevalent, progressive disorders that significantly affect individuals socially, physically, and psychologically, often resulting in various venous abnormalities that hinder effective blood circulation in the lower limbs. This review provides a comprehensive overview of venous diseases, focusing on their pathophysiology, symptoms, causes, risk factors, diagnosis, and complications. The symptoms associated with venous diseases are diverse and can include pain, heaviness, swelling, ulcers, and skin changes. Risk factors such as age, obesity, hormonal influences, and genetic predispositions are discussed in relation to their contribution to disease progression. The therapeutic modalities for managing venous diseases are explored, with a particular emphasis on natural products in alleviating symptoms and improving vascular health. Natural compounds, i.e., flavonoids, play a vital role in the circulatory system, supporting blood vessels and promoting healthy blood flow, in addition to their vasoprotective, antioxidant, anti-inflammatory, and anti-platelet properties. Overall, the ongoing research efforts on the efficacy of natural products will significantly enhance the management of several venous diseases in the coming years.

Diagnosis of cancer therapy-related cardiovascular toxicities: A multimodality integrative approach and future developments

Diagnosing cancer therapy-related cardiovascular toxicities may be a challenge. The interplay between cancer and cardiovascular diseases, beyond shared cardiovascular and cancer risk factors, and the increasingly convoluted cancer therapy schemes have complicated cardio-oncology. Biomarkers used in cardio-oncology include serum, imaging and rhythm modalities to ensure proper diagnosis and prognostic stratification of cardiovascular toxicities. For now, troponin and natriuretic peptides, multimodal cardiovascular imaging (led by transthoracic echocardiography combined with cardiac magnetic resonance or computed tomography angiography) and electrocardiography (12-lead or Holter monitor) are cornerstones in cardio-oncology. However, the imputability of cancer therapies is sometimes difficult to assess, and more refined biomarkers are currently being studied to increase diagnostic accuracy. Advances reside partly in pathophysiology-based serum biomarkers, improved cardiovascular imaging through new technical developments and remote monitoring for rhythm disorders. A multiparametric omics approach, enhanced by deep-learning techniques, should open a new era for biomarkers in cardio-oncology in the years to come.

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.

[Medium- and long-term efficacy of percutaneous mechanical thrombectomy with stent implantation in patients with iliac vein stenosis and thrombosis]

OBJECTIVES

To investigate the medium- and long-term efficacy of percutaneous mechanical thrombectomy (PMT) combined with stent implantation for treatment of iliac vein stenosis with lower extremity deep venous thrombosis (LEDVT).

METHODS

Clinical and follow-up data of 125 patients with iliac vein stenosis and LEDVT who underwent PMT and stent implantation at five hospitals in northern Zhejiang province from January 2017 to June 2021 were collected. The thrombus clearance rate, thrombus recurrence rate, patency rate of iliac vein stents and post-thrombotic syndrome (PTS) occurrence rate were documented, and safety indicators such as bleeding, death, pulmonary embolism, stent fracture and displacement were assessed.

RESULTS

Among 125 patients, for clearance of limb thrombosis, there were 8 cases of grade I (6.4%), 10 cases of grade II (8.0%), and 107 cases of grade III (85.6%). Patients were followed up for a median period of 74 months. According to the Villalta score, the recurrence rates of limb thrombosis at 12, 24 and 36 months were 8.48%, 8.93% and 10.91%; the iliac vein patency rates were 91.52%, 91.07%, and 89.09%; and the incidences of PTS were 5.08%, 5.36% and 6.36%, respectively. There were no major adverse events such as death, massive pulmonary embolism or severe hepatic and renal insufficiency, and no readmission intervention events due to stent fracture or other incidence were found.

CONCLUSIONS

PMT combined with iliac vein stent implantation is effective for patients with iliac vein stenosis complicated by LEDVT with good medium- and long-term efficacy and safety, which is worthy of clinical application.

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

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

The Incidence, Risk Factors and Characteristics of Late (>2 Years) Recurrence of Deep Venous Thrombosis

ObjectiveRecurrent deep venous thrombosis (RDVT) is a relatively frequent phenomenon; however, scarce literature is available on late RDVT (>2 years). This study aimed to investigate the incidence, associated risk factors, and characteristics of late RDVT.MethodsWe conducted a retrospective analysis of patients diagnosed with symptomatic lower extremity deep venous thrombosis (DVT) between April 2017 and April 2022. The incidence and mortality rates of late RDVT, as well as the demographic data, risk factors, and characteristics, were assessed. Additionally, a comprehensive Cox regression analysis was performed to evaluate 14 potential risk factors.ResultsOf the 638 patients with DVT, 89 (13.9%) experienced recurrence during a mean follow-up period of 30.10 ± 15.23 months. The RDVT group comprised 50 males and 39 females (the male-to-female ratio: 50/39), with a mean age of 64.08 ± 13.23 years (the age range: 26-88 years). Among them, early recurrence was observed in 57 (64%) patients, while late recurrence occurred in 32 (36%) after their initial symptomatic DVT episode. Late RDVT predominantly manifested in the contralateral lower extremity. Multivariate Cox regression analysis further identified proximal DVT, immobility, non-retrieved inferior vena cava filter (IVCF), and ≥50% stent extension into the inferior vena cava (IVC) as significant risk factors for late RDVT. Moreover, mortality among patients with late RDVT was low, with 2 (6.25%) dying during the follow-up period.ConclusionsLate RDVT is relatively infrequent within the RDVT cohort and primarily manifests in the contralateral lower extremity. Furthermore, patients with late RDVT have a low mortality rate. Proximal DVT, immobility, non-retrieved IVCF, and ≥50% stent extension into the IVC are strongly correlated with the development of late RDVT.

Plasma microRNA-145-5p as a diagnostic biomarker for acute deep vein thrombosis

Background

Identification of new biomarkers for acute deep vein thrombosis (DVT) that could lower the need for diagnostic imaging to confirm or rule out the diagnosis would be advantageous. microRNA-145-5p (miR-145) has the potential to be a diagnostic marker for acute DVT, but its diagnostic performance has not been evaluated in consecutive patients referred to the hospital with suspected DVT.

Objectives

The aim of this study was to assess the diagnostic performance of miR-145 for the diagnosis of acute lower extremity DVT.

Methods

Patients consecutively referred to the emergency room at Akershus University Hospital (Norway) due to suspicion of acute DVT between June 2021 and July 2023 were included. Within 24 hours of admission, blood was collected for assessment of plasma miR-145 (index test), and whole-leg compression ultrasound (reference standard) was used to confirm or rule out DVT. Cohen's d effect size and area under the receiver operating curve (AUC) were used to estimate the diagnostic performance of miR-145 and D-dimer.

Results

Among 360 included patients, 101 (28%) were diagnosed with DVT. miR-145 showed poor diagnostic performance, as indicated by a Cohen's d of -0.002 (95% CI, -0.241 to 0.216) and an AUC of 0.59 (95% CI, 0.51-0.67). For D-dimer, Cohen's d was 1.66 (95% CI, 1.43-1.89), and the AUC was 0.92 (95% CI, 0.86-0.96).

Conclusion

Plasma levels of miR-145 showed poor diagnostic performance for lower extremity acute DVT among persons referred to the emergency room with clinical signs and symptoms of DVT.

Prognostic Values of Homocysteine and Potassium Levels in Acute Ischemic Stroke Patients after Intravenous Thrombolysis with Recombinant Tissue-Type Plasminogen Activator

Abnormal levels of homocysteine (Hcy) and potassium are associated with poor prognosis of patients with ischemic stroke. Nonetheless, the roles Hcy and potassium in the prognosis of patients with acute ischemic stroke (AIS) receiving intravenous thrombolysis (IVT) with recombinant tissue-type plasminogen activator (rt-PA) are still unknown. Therefore, the purpose of this study is to investigate the association between the levels of Hcy and potassium and clinical prognosis in AIS patients receiving IVT with rt-PA. AIS patients receiving IVT with rt-PA were enrolled in this study. AIS patients were divided into early neurological deterioration (END) and no END group according to the National Institutes of Health Stroke Scale (NIHSS) scores. Moreover, patients were divided into favorable outcome and poor outcome according to the modified Rankin Scale (mRS) scores. Multivariate logistic regression analysis was applied for detecting the risk factors. Four-hundred-twenty-six patients with AIS IVT with rt-PA were recruited: 24 patients showed END within 24 h. One-hundred-fifty-seven patients showed poor outcome. Multivariate analysis showed that higher levels of Hcy level (P < 0.001) and lower levels of potassium level (P < 0.01) were more frequently in patients with END and poor outcomes in AIS patients with IVT at the three-month visit. Taken together, the high Hcy and low potassium levels may be the potential biomarker for AIS patients receiving IVT with rt-PA.

Early Thrombus Removal for Acute Lower Extremity Deep Vein Thrombosis: Update on Inclusion, Technical Aspects, and Postprocedural Management

Acute lower extremity deep vein thrombosis (DVT) is a common disorder with significant associated morbidity, including pain and swelling, as well as the risk of pulmonary embolism (PE), recurrent venous thromboembolism (VTE) and chronic debilitating post-thrombotic syndrome (PTS). Anticoagulation is standard of care for DVT treatment. It assists in reducing thrombus progression and the occurrence of PE, but incomplete DVT resolution increases the risk of recurrent VTE, valvular insufficiency, and PTS. Endovascular DVT interventions, such as catheter-directed thrombolysis, pharmacomechanical thrombectomy, and large-bore mechanical thrombectomy offer an alternative therapeutic strategy for DVT management. This paper will discuss technical factors and current issues when performing lower extremity DVT interventions including patient selection, anticoagulation, choice of device for endovascular thrombus removal, adjunctive techniques, and venous stent management.Level of Evidence: No level of evidence for: review articles, basic science, laboratory investigations, and experimental study articles.

Long-term monitoring and treatment of venous thromboembolic disease: recommendations of the Thromboembolic Disease Group of the Spanish Society of Internal Medicine 2024

Venous thromboembolim (VTE) is a highly prevalent condition that requires long-term monitoring and treatment. This monitoring includes: 1) completing the etiological study and determining the risk of VTE recurrence; 2) establishing the optimal duration of anticoagulant treatment, as well as the type of therapy and its dosage; 3) estimating the risk of bleeding, and 4) identifying the occurrence of chronic complications. This consensus document, prepared by the VTE Group of the Spanish Society of Internal Medicine (SEMI), aims to update and establish consensus recommendations on these aspects. The document focuses on four aspects of management: the first includes risk factors for VTE recurrence after an unprovoked VTE episode and describes the predictive scores of VTE recurrence; the second focuses on risk factors for bleeding; the third provides recommendations for long-term follow-up in VTE, addressing specific considerations for screening chronic thromboembolic pulmonary hypertension and post-thrombotic syndrome of the lower limbs; and the fourth provides guidance on the optimal duration of extended anticoagulant treatment, as well as the type of therapy and its dosage. For each area, an exhaustive literature review was conducted, analyzing the updated VTE clinical guidelines and recent studies. This document is intended to be a guide in the long-term management of VTE based on the most current knowledge.

Low molecular weight heparin dosing regimens after total joint arthroplasty: a prospective, single-center, randomized, double-blind study

BACKGROUND

Low molecular weight heparin (LMWH) has been the standard treatment for preventing venous thromboembolism after total joint arthroplasty. However, the evidence supporting specific LMWH dosing regimens is limited.

OBJECTIVES

This study assessed the efficacy and safety of three enoxaparin dosing regimens to prevent venous thromboembolism.

METHODS

Participants undergoing hip or knee replacement were randomly assigned to receive 20 mg of enoxaparin 6 h postoperatively (Group A), 40 mg 6 h postoperatively (Group B), or 40 mg 12 h postoperatively (Group C). The primary outcomes included thromboembolic and major bleeding events within 3 months, while the secondary outcomes comprised ecchymosis, wound exudation, drainage volume, allogeneic red blood cell transfusion, and first postoperative day hemoglobin levels.

RESULTS

A total of 536 patients were analyzed. The occurrence of thromboembolic events was comparably low across all groups. Group C exhibited the lowest postoperative ecchymosis rate at 19.3%, significantly less than Group A (32.8%, p = 0.004) and Group B (37.7%, p < 0.001). Ecchymosis rates were about double in Group A and 1.5 times higher in Group B compared to Group C. Significant differences were also observed in 24-hour and total postoperative drainage volumes, with Group B having higher volumes than the other groups.

CLINICAL TRIAL REGISTRATION

This trial was prospectively registered at the China Clinical Trials Registry (registration date: November 14, 2021; registration number: ChiCTR2100053191).

CONCLUSION

No significant differences in venous thromboembolism rates were seen between the tested enoxaparin dosing regimens after total joint arthroplasty. The 40 mg dose administered 12 h after surgery was associated with reduced postoperative ecchymosis and drainage volumes without an increased thrombosis risk, suggesting it is a safer and more effective option than earlier or lower dosages.

Clinical application of standardization right thoracic incision for thoracoscopic thymic tumor resection

BACKGROUND

With the continuous development of minimally invasive thoracic surgery, thoracoscopic thymectomy has become a routine operation. This method, now widely recognized, better protects lung function, reduces intraoperative blood loss and pain, and shortens postoperative hospital stay. We now introduce a standardized right thoracic incision for thoracoscopic thymic tumor resection, which has achieved favorable clinical outcomes.

METHODS

This retrospective study involves 63 patients who underwent standardized right thoracic incision for thoracoscopic thymic tumor resection from October 2022 to January 2024. We analyzed the relevant clinical data, including postoperative pathological diagnosis, operation time, intraoperative blood loss, chest tube drainage duration, postoperative hospital stay, and follow-up data.

RESULTS

All 63 patients underwent thoracoscopic surgery. Thoracoscopic surgery excised thymic tumors and mediastinal fat in 62 cases, while 1 case of thymic carcinoma underwent thoracoscopic biopsy due to invasion of the superior vena cava and innominate vein. Postoperative pathological diagnosis revealed thymoma in 35 cases (33 cases of thymoma and 2 cases of thymic adenocarcinoma). R0 resection was achieved in 33 cases and R1 resection in 1 case. Additionally, 2 patients diagnosed with thymic adenocarcinoma were advised to undergo postoperative radiotherapy. Postoperative pathological diagnosis of the other 28 cases showed thymus hyperplasia in 13 cases and thymus cysts in 15 cases. The mean operation time was 57.3 ± 14.2 min, and intraoperative blood loss was 22.5 ± 14.7 ml. The mean chest tube drainage duration was 2.7 ± 1.3 days, and the postoperative hospital stay was 3.7 ± 1.4 days. No secondary operations were required, and no severe complications or mortality were observed during the perioperative period. All patients were discharged smoothly after surgery. Ten patients were not followed up due to recent surgery. The remaining 53 patients were followed up for 6 to 12 months, with no recurrence or distant metastasis observed.

CONCLUSION

The standardized right thoracic incision for thoracoscopic thymic tumor resection simplifies the procedure of thymectomy. The operation's risk points are relatively fixed, making it safe and feasible. It is easy for the operator to master, and the thymic tumor resection rate is high. It possesses characteristics of being minimally invasive, enabling rapid recovery, having fewer complications, and requiring simple perioperative management.

Prophylactic Dose of Rivaroxaban Versus Warfarin for the Treatment of Isolated Calf Muscle Vein Thrombosis: A Retrospective Propensity Score-Matched Analysis

BACKGROUND

Prophylactic dose of rivaroxaban is often used in treatment of isolated calf muscle vein thrombosis (ICMVT); nevertheless, its effect is less reported. This study aims to evaluate short-term outcomes in patients with ICMVT who received prophylactic dose of rivaroxaban or warfarin therapy.

METHODS

A retrospective analysis of 472 ICMVT patients who received 2 different treatment regimens was undertaken. Propensity score matching method was used to balance the confounding effect of baseline clinical data. Chi-squared test and logistic regression analysis were used to compare outcomes (venous thromboembolism events, bleeding events, complete clot resolution) according to the type of treatment regimens before and after propensity score matching. Univariate and multivariable analysis were used to investigate risk factors for incomplete clot resolution of ICMVT after propensity score matching.

RESULTS

242 ICMVT patients received prophylactic dose of rivaroxaban (rivaroxaban group, RG), and 230 received warfarin (warfarin group, WG). After propensity score matching, 156 patients were included in each group; Venous thromboembolism (VTE) events occurred in 14 (9.0%) patients in the RG and 10 (6.4%) in the WG (P = 0.395); no major bleeding events occurred in each group, and clinically relevant nonmajor bleeding events occurred in 5 (3.2%) patients in the RG and 10 (6.4%) in the WG (P = 0.186); complete clot resolution at 3 months occurred in 80 (51.3%) patients in the RG and 100 (64.1%) in the WG (P = 0.022). Logistic regression analysis showed that there were no significant differences between RG and WG in VTE events (odds ratio 1.439, 95% confidence interval 0.619-3.347, P = 0.397) and clinically relevant nonmajor bleeding events (odds ratio 0.483, 95% confidence interval 0.161-1.449, P = 0.194); it revealed that complete clot resolution rate at 3 months was different in the 2 groups (odds ratio 0.589, 95% confidence interval 0.375-0.928, P = 0.022). Treatment regimens (prophylactic dose of rivaroxaban), thrombosis (maximum diameter >7 mm), and risk factors for VTE (nonsurgery risk factors, mainly referring to active malignancy) were risk factors for incomplete clot resolution of ICMVT (P < 0.05).

CONCLUSIONS

In this retrospective study with a short-term follow-up, ICMVT patients who received prophylactic dose of rivaroxaban had no significant differences in VTE and bleeding events compared to those who received warfarin therapy (the overall INR >2.0 for >50% of the time); but it was not conducive to complete clot resolution.

External validation of the Leiden Thrombosis Recurrence Risk Prediction models (L-TRRiP) for the prediction of recurrence after a first venous thrombosis in the Heart and Vascular Health study

Background

Long-term outcome after a first venous thromboembolism (VTE) might be optimized by tailoring anticoagulant treatment duration on individual risks of recurrence and major bleeding. The L-TRRiP models (A-D) were previously developed in data from the Dutch Multiple Environment and Genetic Assessment of Risk Factors for Venous thrombosis study to predict VTE recurrence.

Objectives

We aimed to externally validate models C and D using data from the United States Heart and Vascular Health (HVH) study.

Methods

Data from participants with a first VTE who discontinued initial anticoagulant therapy were used to determine model performance. Missing data were imputed, and results were pooled according to Rubin's rules. To determine discrimination, Harrell's C-statistic was calculated. To assess calibration, the observed/expected (O/E) ratio was estimated, and calibration plots were created, in which we accounted for the competing risk of death. A stratified analysis based on age <70 or >70 years was performed.

Results

Of 1430 participants from the HVH study, 187 experienced an unprovoked VTE recurrence during follow-up. The C-statistics of L-TRRIP models C and D were 0.62 (95% CI, 0.56-0.67) and 0.61 (95% CI, 0.55-0.67), respectively. The O/E ratio (1.00; 95% CI, 0.84-1.17 and 1.09; 95% CI, 0.91-1.27, respectively) and calibration plots indicated good calibration. The discrimination was similar between participants <70 or >70 years, whereas overall calibration was lower in participants <70 years.

Conclusion

The L-TRRiP models showed moderate discrimination and good calibration in a different population and can be used to guide clinical decision making. To assess the added value in daily clinical practice, a management study is needed.

Evaluation of Inflammation and Platelet Apoptosis Parameters in Obese Patients in Various Types of Anticoagulant Prophylaxis of Venous Thromboembolic Complications in Context of COVID-19

INTRODUCTION: The physical inactivity, hypoventilation, as well as chronic inflammation in obese patients aggravates their condition in various diseases. These features have become important with the advent of the COVID-19 pandemic, in which inflammation and platelet-activated coagulopathy are closely linked. AIM: To study laboratory parameters of inflammation and platelet apoptosis in obese patients using various types of anticoagulant prophylaxis of venous thromboembolic complications with the underlying COVID-19. MATERIALS AND METHODS: The study included 370 patients with COVID-19. Depending on the presence or absence of obesity and the type of parenteral anticoagulant, patients in our study were divided into groups: group 1 — non-obese + low molecular weight heparin (LMWH) (n = 114), group 2 — non-obese + unfractionated heparin (UFH) (n = 58), group 3 — obesity + LMWH (n = 76), group 4 — obesity + UFH (n = 66). The incidence of venous thromboembolic complications (VTEC), bleeding, general markers of the acute phase of inflammation, and specific markers of platelet apoptosis (phosphatidylserine and calreticulin) have been analyzed. RESULTS: At the end of hospital treatment, a decrease in ferritin levels was noted in patients both with and without obesity receiving LMWH. The concentration of calreticulin was higher in patients taking LMWH (groups 1 and 3). Phosphatidylserine levels were high in patients receiving LMWH only if they were obese. In patients taking UFH compared to LMWH, a high incidence of pulmonary embolism (PE) without a source (13.6% of cases versus 2.6%, respectively, p = 0.029) and PE with a source in the lower extremities (9.1% of cases versus 0%, respectively, p = 0.018) was found. When using LMWH, a lower incidence of bleeding was observed compared to using UFH (5.3% of cases versus 16.7%, respectively, p = 0.056). CONCLUSION: The levels of phosphatidylserine and calreticulin are higher in obese patients receiving LMWH. At the same time, patients in this group have a low incidence of VTEC and hemorrhagic complications compared to the group of patients taking UFH.

Analysis of the diagnostic value of coagulation markers and coagulation function indices on the occurrence of DIC in sepsis and its prognosis

Sepsis is a life-threatening condition that has the potential to multiple organ dysfunction and mortality. One of its frequent complications is disseminated intravascular coagulation (DIC), characterized by hyperactive clotting mechanisms that cause widespread clot formation and tissue damage. This study aimed to investigate early diagnostic markers of sepsis-associated DIC by comparing inflammatory factor levels, 28-day survival rates, coagulation function, and markers between patients with sepsis (non-DIC group) and those with sepsis-induced DIC (DIC group). The study analyzed the diagnostic efficacy of coagulation function and markers in predicting the occurrence and prognosis of sepsis-associated DIC, presenting survival curves. Results indicated significantly increased levels of APTT, TAT, tPAIC, PIC, and sTM in the DIC group compared to the non-DIC group. Sequential Organ Failure Assessment (SOFA) scores on days 1, 3, and 7 were notably lower in the non-DIC group. Correlation analysis revealed positive associations between PT, APTT, TAT, tPAIC, PIC, sTM levels, and SOFA scores, as well as negative associations with Fib and SOFA scores. Survival curves showed substantially lower mortality rates in the non-DIC group, highlighting significant survival disparities between groups. Combining all four coagulation indicators (TAT+ tPAIC + PIC + sTM) showed promising diagnostic value in evaluating disease severity, early DIC diagnosis, and sepsis prognosis.

Developmental or Procedural Vena Cava Interruption and Venous Thromboembolism: A Review

The inferior vena cava (IVC) and superior vena cava are the main conduits of the systemic venous circulation into the right atrium. Developmental or procedural interruptions of vena cava might predispose to stasis and deep vein thrombosis (DVT) distal to the anomaly and may impact the subsequent rate of pulmonary embolism (PE). This study aimed to review the various etiologies of developmental or procedural vena cava interruption and their impact on venous thromboembolism. A systematic search was performed in PubMed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines per each clinical question. For management questions with no high-quality evidence and no mutual agreements between authors, Delphi methods were used. IVC agenesis is the most common form of congenital vena cava interruption, is associated with an increased risk of DVT, and should be suspected in young patients with unexpected extensive bilateral DVT. Surgical techniques for vena cava interruption (ligation, clipping, and plication) to prevent PE have been largely abandoned due to short-term procedural risks and long-term complications, although survivors of prior procedures are occasionally encountered. Vena cava filters are now the most commonly used method of procedural interruption, frequently placed in the infrarenal IVC. The most agreed-upon indication for vena cava filters is for patients with acute venous thromboembolism and coexisting contraindications to anticoagulation. Familiarity with different forms of vena cava interruption and their local and systemic adverse effects is important to minimize complications and thrombotic events.

Novel Challenges and Therapeutic Options for Pulmonary Embolism and Deep Vein Thrombosis

Acute pulmonary embolism (PE), often resulting from deep vein thrombosis (DVT), is the third most frequent cause of cardiovascular death and is associated with increasing incidence, causing considerable morbidity and mortality. This review aims to evaluate the efficacy, safety, and outcomes of treatment options in the management of acute PE and DVT, encompassing both established and emerging technologies, such as catheter-directed thrombolysis, aspiration thrombectomy, and other endovascular techniques. A comprehensive literature review was conducted, assessing clinical studies, trials, and case reports that detail the use of percutaneous interventions for PE and DVT and analyzing the advantages and disadvantages of each percutaneous system. Several percutaneous treatments have shown promising results, especially in cases where rapid thrombus resolution is critical, such as in high- and intermediate-high-risk patients. The incidence of major complications, such as bleeding, remains a consideration, though it is generally manageable with proper patient selection and technique. It is fundamentally important to tailor the specific treatment strategy to the clinical and anatomical characteristics of each patient. Percutaneous treatments for acute PE and DVT represent valuable options in the therapeutic arsenal, offering enhanced outcomes in appropriately selected patients. Ongoing advancements in technology and technique, along with comprehensive clinical trials, are essential to further define the role and optimize the use of these interventions.

Edoxaban for 12 vs. 3 months in cancer-associated isolated distal deep vein thrombosis according to different doses: insights from the ONCO DVT study

BACKGROUND

The ONCO DVT study revealed the superiority of 12-month relative to 3-month edoxaban treatment for cancer-associated isolated distal deep vein thrombosis (DVT) regarding the thrombotic risk.

METHODS AND RESULTS

In this pre-specified subgroup analysis of the ONCO DVT study, we stratified the patients into those with a standard edoxaban dose (60 mg/day; N = 151) and those with a reduced edoxaban dose (30 mg/day; N = 450) and evaluated the clinical outcomes for the 12- and 3-month treatments. The cumulative 12-month incidence of symptomatic recurrent venous thromboembolism was lower in the 12-month than 3-month group for both the 60 mg (1.3% vs. 11.6%, P = 0.02; odds ratio [OR], 0.12; 95% confidence interval [CI], 0.01-0.97) and 30 mg (1.1% vs. 7.6%, P = 0.002; OR, 0.14; 95% CI, 0.03-0.60) edoxaban subgroups, which was consistent across the edoxaban doses without a significant interaction (P = 0.90). The 12-month cumulative incidence of major bleeding was higher in the 12-month group than in the 3-month group for the 60 mg edoxaban subgroup (14.3% vs. 4.4%, P = 0.046; OR, 3.61; 95% CI, 0.97-13.52), whereas it did not significantly differ between the two groups for the 30 mg edoxaban subgroup (8.7% vs. 8.6%, P = 0.89; OR, 0.97; 95% CI, 0.49-1.91), signalling there was a potential interaction (P = 0.07).

CONCLUSIONS

A 12-month edoxaban regimen for cancer-associated isolated distal DVT was consistently superior to a 3-month regimen, across the edoxaban doses for the thrombotic risk. However, caution was suggested for the standard dose of edoxaban due to the potential for an increased risk of bleeding with prolonged anticoagulation therapy.

TRIAL REGISTRATION NUMBER

NCT03895502 (ONCO DVT Trial): https://classic.clinicaltrials.gov/ct2/show/NCT03895502.

Recurrence in isolated distal DVT after anticoagulation: a systematic review and meta-analysis of axial and muscular venous thrombosis

OBJECTIVE

To identify recurrent venous thromboembolism (VTE) after discontinuation of anticoagulation in patients with isolated distal deep vein thrombosis based on its anatomic localization (axial or muscular veins).

METHODS

Data were sourced from PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov databases in the time period up to October 2023. The study followed PRISMA guidelines using a registered protocol (CRD42023443029). Studies reporting recurrent VTE in patients with axial or muscular DVT were included in the analysis.

RESULTS

Five studies with a total of 1,403 participants were evaluated. The results showed a pooled odds ratio of 1.12 (95% confidence interval 0.77-1.63) between axial and muscular DVT. Heterogeneity was low (I2 = 0%, p = 0.91) and there was no significant difference in the rate of recurrent VTE between axial and muscular DVT in each subgroup.

CONCLUSIONS

Muscular and axial DVT showed comparable recurrent VTE rates after anticoagulation. However, uncertainties regarding the possibility of recurrence affecting the popliteal vein or resulting in pulmonary embolism following muscular DVT anticoagulation persisted. Randomized trials in patients with isolated distal DVT are still needed to clarify its prognosis for different anatomical thrombus locations.

Subsegmental Pulmonary Embolism

Subsegmental pulmonary embolism (SSPE) is increasingly diagnosed with the growing use and technological advancements of multidetector computed tomography pulmonary angiography. Its diagnosis is challenging, and some presumed SSPE may actually represent imaging artifacts. Indirect evidence and results from small observational studies suggest that SSPE may be more benign than more proximal pulmonary embolism, and may thus not always require treatment. Therefore, guidelines suggest to consider a management strategy without anticoagulation in selected patients with SSPE at low risk of recurrent venous thromboembolism (VTE), in whom proximal deep vein thrombosis is excluded. Recently, a large prospective study among low-risk patients with SSPE who were left untreated showed a higher VTE recurrence risk than initially deemed acceptable by the investigators, and thus was prematurely interrupted after recruitment of 97% of the target population. However, the risk-benefit ratio of anticoagulation for low-risk patients with SSPE remains unclear, and results from randomized trials are needed to answer the question about their optimal management.

Cost-Effectiveness of Performing Reference Ultrasonography in Patients with Deep Vein Thrombosis

BACKGROUND

 The diagnosis of recurrent ipsilateral deep vein thrombosis (DVT) with compression ultrasonography (CUS) may be hindered by residual intravascular obstruction after previous DVT. A reference CUS, an additional ultrasound performed at anticoagulant discontinuation, may improve the diagnostic work-up of suspected recurrent ipsilateral DVT by providing baseline images for future comparison.

OBJECTIVES

 To evaluate the cost-effectiveness of routinely performing reference CUS in DVT patients.

METHODS

 Patient-level data (n = 96) from a prospective management study (Theia study; NCT02262052) and claims data were used in a decision analytic model to compare 12 scenarios for diagnostic management of suspected recurrent ipsilateral DVT. Estimated health care costs and mortality due to misdiagnosis, recurrent venous thromboembolism, and bleeding during the first year of follow-up after presentation with suspected recurrence were compared.

RESULTS

 All six scenarios including reference CUS had higher estimated 1-year costs (€1,763-€1,913) than the six without reference CUS (€1,192-€1,474). Costs were higher because reference CUS results often remained unused, as 20% of patients (according to claims data) would return with suspected recurrent DVT. Estimated mortality was comparable in scenarios with (14.8-17.9 per 10,000 patients) and without reference CUS (14.0-18.5 per 10,000). None of the four potentially most desirable scenarios included reference CUS.

CONCLUSION

 One-year health care costs of diagnostic strategies for suspected recurrent ipsilateral DVT including reference CUS are higher compared to strategies without reference CUS, without mortality benefit. These results can inform policy-makers regarding use of health care resources during follow-up after DVT. From a cost-effectiveness perspective, the findings do not support the routine application of reference CUS.

Predictive value of Caprini risk assessment model, D-dimer, and fibrinogen levels on lower extremity deep vein thrombosis in patients with spontaneous intracerebral hemorrhage

Introduction

Research indicates that individuals experiencing hemorrhagic stroke face a greater likelihood of developing lower extremity deep vein thrombosis (DVT) compared to those with ischemic stroke. This study aimed to assess the predictive capacity of the Caprini risk assessment model (RAM), D-dimer (D-D) levels, and fibrinogen (FIB) levels for lower extremity DVT in patients with spontaneous intracerebral hemorrhage (sICH).

Methodology

This study involved a retrospective analysis of medical records from all sICH patients admitted to Shanghai General Hospital between June 2020 and June 2023. Within 48 h of admission, patients underwent routine screening via color Doppler ultrasonography (CDUS). Patients were categorized into the DVT and control groups based on the occurrence of lower extremity DVT during hospitalization. Differences in Caprini RAM, D-dimer, and FIB levels between the two groups were compared. The sensitivity and specificity of combined Caprini RAM, peripheral blood D-dimer, and FIB levels in predicting lower extremity DVT in sICH patients were analyzed. Receiver operating characteristic (ROC) curves assessed the overall predictive accuracy of Caprini RAM, D-D, and FIB levels.

Results

The study involving 842 sICH patients revealed 225 patients with DVT and 617 patients without DVT. Caprini RAM, D-D, and FIB levels were significantly higher in the DVT group compared to the control group (P < 0.05). Sensitivity values for Caprini RAM, D-D, and FIB levels in predicting lower extremity DVT in sICH patients were 0.920, 0.893, and 0.680, respectively, while specificities were 0.840, 0.680, and 0.747, respectively. The ROC curve analysis demonstrated an area under the curve (AUC) of 0.947 for combined DVT prediction, with 97.33% sensitivity and 92.00% specificity, indicating superior predictive value compared to individual applications of Caprini RAM, D-D, and FIB levels.

Conclusion

The combined utilization of Caprini RAM, D-D, and FIB levels holds significant clinical relevance in predicting lower extremity DVT in sICH patients.

Pulmonary Embolism in Pregnancy: A Review for Clinical Practitioners

Diagnostic and therapeutic decision-making in pregnancy with suspected pulmonary embolism (PE) is challenging. European and other international professional societies have proposed various recommendations that are ambiguous, probably due to the unavailability of randomized controlled trials. In the following sections, we discuss the supporting diagnostic steps and treatments. We suggest a standardized diagnostic work-up in pregnant patients presenting with symptoms of PE to make evidence-based diagnostic and therapeutic decisions. We strongly recommend that clinical decisions on treatment in pregnant patients with intermediate- or high-risk pulmonary embolism should include a multidisciplinary team approach involving emergency physicians, pulmonologists, angiologist, cardiologists, thoracic and/or cardiovascular surgeons, radiologists, and obstetricians to choose a tailored management option including an interventional treatment. It is important to be aware of the differences among guidelines and to assess each case individually, considering the specific views of the different specialties. This review summarizes key concepts of the diagnostics and acute management of pregnant women with suspected PE that are supportive for the clinician on duty.

Diagnosis and treatment of deep vein thrombosis of the lower and upper limbs. 2024 recommendations of the venous thromboembolism group of the Spanish Society of Internal Medicine

Deep vein thrombosis (DVT) of the limbs is a common disease and causes significant morbidity and mortality. It is frequently the prelude to pulmonary embolism (PE), it can recur in 30% of patients and in 25-40% of cases they can develop post-thrombotic syndrome (PTS), with a significant impact in functional status and quality of life. This document contains the recommendations on the diagnosis and treatment of acute DVT from the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI). PE and thrombosis of unusual venous territories (cerebral, renal, mesenteric, superficial, etc.) are outside its scope, as well as thrombosis associated with catheter and thrombosis associated with cancer, which due to their peculiarities will be the subject of other positioning documents of the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI).

Management of isolated distal deep vein thrombosis

Isolated distal deep vein thrombosis (DVT) represents up to 50% of all lower limb DVT in ultrasound series and is a frequent medical condition, which management is not well established. Data arising from registries and non-randomized studies suggest that most distal DVTs do not extend to the proximal veins and have an uneventful follow-up when left untreated. This data had some impact on international recommendations like the American College of Chest Physicians (ACCP), whose last version stated that ultrasound surveillance might be an option for selected low-risk patients. However, robust data arising from randomized studies are scarce. Indeed, only seven randomized trials assessing the need for anticoagulation for calf DVT have been published. Many of these trials had an open-label design and were affected by methodological limitations. When considering randomized placebo-controlled trials, one included low-risk patients and was hampered by a limited statistical power (CACTUS study). Nevertheless, data from this trial tend to confirm that the use of therapeutic anticoagulation in low-risk patients with symptomatic calf DVT is not superior to placebo in reducing VTE but is associated with a higher risk of bleeding. A second randomized placebo-controlled trial did not assess the necessity of anticoagulant treatment but rather the long-term risk of recurrence and compared 6 weeks versus 12 weeks of treatment with rivaroxaban (RIDTS study). Finally, the last available randomized trial compared a 3-month versus a 12-month edoxaban treatment in patients with cancer and mainly asymptomatic distal DVT, detected by systematic compression ultrasonography. Overall, available data suggest that the use of therapeutic anticoagulation in low-risk patients with symptomatic calf DVT is not superior to placebo in reducing VTE. High risk patients (previous VTE, active cancer, inpatients) might benefit from a course of anticoagulant treatment. However, the optimal anticoagulant intensity and duration are uncertain and further studies are needed.

Hypertensive Disorders of Pregnancy and Pre-Pregnancy Hypertension with Subsequent Incident Venous Thromboembolic Events

Hypertensive disorders of pregnancy (HDP) and pre-pregnancy hypertension contribute to maternal morbidity and mortality. We examined the association of HDP and pre-pregnancy hypertension with subsequent venous thromboembolic (VTE) events. The retrospective cohort study included 444,859 women with ≥1 live, singleton birth in South Carolina (2004-2016). Hospital and emergency department visit and death certificate data defined incident VTE, HDP, and pre-pregnancy hypertension. Birth certificate data also defined the exposures. Adjusted Cox proportional hazards methods modeled VTE events risk. Of the cohort, 2.6% of women had pre-pregnancy hypertension, 5.8% had HDP, 2.8% had both pre-pregnancy hypertension and HDP (both conditions), and 88.8% had neither condition. The risk of incident VTE events within one year of delivery was higher in women with HDP (hazard ratio [HR] = 1.62, 95% confidence interval [CI]: 1.15-2.29) and both conditions (HR = 2.32, 95% CI: 1.60-3.35) compared to those with neither condition as was the risk within five years for women with HDP (HR = 1.35, 95% CI: 1.13-1.60) and for women with both conditions (HR = 1.82, 95% CI: 1.50-2.20). One- and five-year risks did not differ in women with pre-pregnancy hypertension compared to women with neither condition. Compared to non-Hispanic White (NHW) women with neither condition, the incident VTE event risk was elevated within five years of delivery for NHW (HR = 1.29, 95% CI: 1.02-1.63; HR = 1.59, 95% CI: 1.16-2.17) and non-Hispanic Black (NHB; HR = 1.51, 95% CI: 1.16-2.96; HR = 2.08, 95% CI: 1.62-2.66) women with HDP and with both conditions, respectively, and for NHB women with pre-pregnancy hypertension (HR = 1.50, 95% CI: 1.09-2.07). VTE event risk was highest in women with HDP, and the event rates were higher in NHB women than in NHW women in the same exposure group.

[Pelvic vein thrombosis : Current treatment options and importance of recanalization procedures]

Venous thrombosis is a frequent disorder. A distinction is made between an acute phase of the disease and a chronic manifestation, the postthrombotic syndrome. In particular, proximal venous thrombosis/pelvic vein thrombosis can cause a life-threatening pulmonary embolism during the acute phase of the disease. The postthrombotic syndrome is characterized by the remodeling of the affected venous section, which is often caused by inflammation. Locally, the typical clinical finding is caused by scarred stricture of the vein with restricted drainage and peripheral venous hypertension. Acute thrombosis should be primarily treated by therapeutic anticoagulation and compression therapy of the affected extremity. The duration of these measures depends on clinical presentation, cause (provoked, unprovoked) and risk factors for venous thrombosis/recurrent thrombosis. Venous revascularization procedures are important both in the acute phase of the disease and in the treatment of postthrombotic syndrome. The recanalization treatment is mostly carried out as an endovascular or hybrid intervention and venous bypass procedures are reserved for special situations.

Preeclampsia and Long-Term Risk of Venous Thromboembolism

Importance

As venous thromboembolism (VTE) remains one of the leading causes of maternal mortality, identifying women at increased risk of VTE is of great importance. Preeclampsia is a pregnancy-induced hypertensive disorder with generalized endothelial dysfunction. Some studies suggest that preeclampsia is associated with an increased risk of VTE, but much controversy exists.

Objective

To examine the association between preeclampsia and the risk of VTE during pregnancy, during the puerperium, and after the puerperium.

Design, Setting, and Participants

This observational cohort study used Danish nationwide registries to identify all eligible primiparous women who gave birth in Denmark from January 1, 1997, to December 31, 2016. The women were followed up from primiparous pregnancy to incident VTE, emigration, death, or the end of the study (December 31, 2016). Statistical analyses were carried out from January to May 2023.

Exposure

Preeclampsia during primiparous pregnancy.

Main Outcomes and Measure

The main outcome was incident VTE, and the secondary outcome was all-cause mortality.

Results

A total of 522 545 primiparous women (median age, 28 years [IQR, 25-31 years]) were included, and 23 330 (4.5%) received a diagnosis of preeclampsia. Women with preeclampsia were of similar age to women without preeclampsia but had a higher burden of comorbidities. During a median follow-up of 10.2 years (IQR, 5.2-15.4 years), preeclampsia was associated with a higher incidence of VTE compared with no preeclampsia (incidence rate, 448.8 [95% CI, 399.9-503.5] vs 309.6 [95% CI, 300.6-319.9] per 1000 patient-years, corresponding to an unadjusted hazard ratio [HR] of 1.45 [95% CI, 1.29-1.63] and an adjusted HR of 1.43 [95% CI, 1.27-1.61]). When stratified according to the subcategories of VTE, preeclampsia was associated with an increased rate of deep vein thrombosis (unadjusted HR, 1.51 [95% CI, 1.32-1.72] and adjusted HR, 1.49 [95% CI, 1.31-1.70]) as well as pulmonary embolism (unadjusted HR, 1.39 [95% CI, 1.09-1.76]; adjusted HR, 1.36 [95% CI, 1.08-1.73]). These findings held true in landmark analyses during pregnancy, during the puerperium, and after the puerperium.

Conclusions and Relevance

This cohort study suggests that preeclampsia was associated with a significantly increased risk of VTE during pregnancy, during the puerperium, and after the puerperium, even after thorough adjustment. Future studies should address how to improve the clinical management of women with a history of preeclampsia to prevent VTE.

[Recommendations for thromboembolic disease in oncological processes. A view from primary care]

Venous thromboembolic disease (VTE) is a frequent complication in patients diagnosed with cancer and a cause of morbidity and mortality. Approximately 20% of thromboembolic episodes develop in association with active cancer. On the other hand, it is estimated that about 2-12% of cases, the thromboembolic episode is the first manifestation of an occult cancer, diagnosed at that time or subsequently, which offers an opportunity for early diagnosis and treatment. There are multiple factors that contribute to increase the risk of VTE in oncological patients in relation to specific characteristics of the patient, the tumor and the treatments. Knowledge of these risk factors will contribute to early diagnosis when signs of VTE appear, as well as the assessment of thromboprophylaxis if indicated. The diagnosis of VTE in patients with cancer does not differ of those who do not suffer from it. Regarding the treatment of VTE in these patients, low molecular weight heparin (LMWH), direct acting anticoagulants (DACs) and antivitamin K (VKA) are the most commonly used, although the dosing regimen and length are not clear yet. The management of these patients should be interdisciplinary and early, so the primary care physician plays a key role in this process as he/she is liaise with his/her patients. It is also necessary to update knowledge in order to improve the care of these patients. For these reasons, this document has been prepared by the Working Group on Vasculopathies of the Spanish Society of Primary Care Physicians (SEMERGEN) whose objective is to present the available information regarding the management of VTE that may appear in oncological patients, as well as the assessment of thromboprophylaxis and treatment, if appropriate, from an approach focused on a primary care field.

Unprovoked Venous Thromboembolism: The Search for the Cause

Venous thromboembolism (VTE) is a common vascular disorder encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE). There is no data on global estimates of VTE prevalence and incidence. Most patients with unprovoked VTE require secondary thromboprophylaxis upon the completion of the primary treatment phase if they have no high bleeding risk. Risk prediction models can help identify patients at low VTE recurrence risk who may discontinue anticoagulation upon the completion of the primary treatment phase.

Uncommon Cases of Venous Thromboembolism

There is a growing incidence of new cases of venous thromboembolismworldwide.Some of these patients do have a predisposition to the development of thrombosis, some of them do however have various risk factors associated with this event, but few of them have unrecognized etiology. This paper aimsto describe different scenarios of venous thromboembolism.

Prevention, Diagnostics and Treatment of Deep Vein Thrombosis. Russian Experts Consensus

The guidelines are developed in accordance with the requirements of the Ministry of Health of the Russian Federation by the all-Russian public organization «Association of Phlebologists of Russia» with participation of the Association of Cardiovascular Surgeons of Russia, the Russian Society of Surgeons, the Russian Society of Angiologists and Vascular Surgeons, the Association of Traumatologists and Orthopedists of Russia, the Association of Oncologists of Russia, the Russian Society of Clinical Oncology, Russian Society of Oncohematologists, Russian Society of Cardiology, Russian Society of Obstetricians and Gynecologists.

Isolated distal deep vein thrombosis: What have we learnt from the OPTIMEV study?

The OPTIMEV (OPTimisation de l'Interrogatoire dans l'évaluation du risque throMbo-Embolique Veineux) study has provided some important and innovative information for the management of lower extremity isolated distal deep vein thrombosis (distal DVT). Indeed, if distal deep-vein thrombosis (DVT) therapeutic management is nowadays still debated, before the OPTIMEV study, the clinical relevance of these DVT itself was questioned. Via the publication of 6 articles, between 2009 and 2022, assessing risk factors, therapeutic management, and outcomes of 933 patients with distal DVT we were able to demonstrate that: - When distal deep veins are systematically screened for suspicion of DVT, distal DVT are the most frequent clinical presentation of the venous thromboembolic disease (VTE). This is also true in case of combined oral contraceptive related VTE. - Distal DVT share the same risk factors as proximal DVT and constitute two different clinical expressions of the same disease: the VTE disease. However, the weight of these risk factors differs: distal DVT are more often associated with transient risk factors whereas proximal DVT are more associated with permanent risk factors. - Deep calf vein and muscular DVT share the same risk factors, short and long-term prognoses. - In patients without history of cancer, risk of unknown cancer is similar in patients with a first distal or proximal DVT. - After 3years and once anticoagulation has been stopped, distal DVT recur twice less as proximal DVT and mainly as distal DVT; However, in cancer patients, prognosis of distal and proximal DVT appear similar in terms of death and VTE recurrence.

Thrombosis Models: An Overview of Common In Vivo and In Vitro Models of Thrombosis

Occlusions in the blood vessels caused by blood clots, referred to as thrombosis, and the subsequent outcomes are leading causes of morbidity and mortality worldwide. In vitro and in vivo models of thrombosis have advanced our understanding of the complex pathways involved in its development and allowed the evaluation of different therapeutic approaches for its management. This review summarizes different commonly used approaches to induce thrombosis in vivo and in vitro, without detailing the protocols for each technique or the mechanism of thrombus development. For ease of flow, a schematic illustration of the models mentioned in the review is shown below. Considering the number of available approaches, we emphasize the importance of standardizing thrombosis models in research per study aim and application, as different pathophysiological mechanisms are involved in each model, and they exert varying responses to the same carried tests. For the time being, the selection of the appropriate model depends on several factors, including the available settings and research facilities, the aim of the research and its application, and the researchers' experience and ability to perform surgical interventions if needed.

Comparison of endovenous laser ablation and conservative treatment in acute thrombophlebitis of the varicose great saphenous vein: rationale, design and first results of clinical trial

Thrombophlebitis of the superficial lower limb veins is one of the most common complications of chronic vein disease. Nowadays a long-term (at least 45 days) subcutaneous injection of fondaparinux sodium or heparin in combination with elastic compression of the limb is recommended for treatment of superficial vein thrombosis with a moderate risk of thrombus propagation to deep venous system. However, long-term use of anticoagulants is not always possible and sometimes contraindicated. Endovenous laser ablation (EVLA) around thrombus-free junction of great or small saphenous veins without subsequent long-term use of anticoagulants seems to be a promising intervention for treatment of acute thrombophlebitis of varicose superficial veins.

The prospective single-center randomized open-label clinical trial was dedicated for comparison the efficacy and safety of three following treatments options for patients with acute thrombosis of the varicose great saphenous vein and location of thrombi in the trunk and/ or its large inflows: EVLA close to saphenous vein junction without anticoagulation, EVLA and 7 days of anticoagulation and noninvasive treatment with anticoagulation for 45 days (subcutaneous injections of the fondaparinux 2,5 mg). Class 2 compression stockings are used in all patients. Adverse outcomes are recorded at 7, 45 and 90 days after randomization. These include the progression of superficial vein thrombosis, recurrent superficial vein thrombosis, thrombosis involvement of the superficial segment of the perforating vein up to the fascia, deep vein thrombosis according to compression ultrasound, and pulmonary embolism with symptoms. Bleedings according to the World Society of Thrombosis and Hemostasis and the Academic Research Consortium classification as well other complications are also recorded. The first 30 patients included in the study have a low incidence of venous thrombosis risk factors and localization of the thrombus relatively far from the saphenofemoral junction. EVLA resulted in persistent cessation of venous blood flow at the intervention site. New episodes of venous thrombosis were noted only in the group of medical treatment — deep vein thrombosis of the contralateral tibia 5 days after stopping of 45-day treatment with fondaparinux and thrombus in the recanalized inflow of the great saphenous vein without involving its trunk at the 21st day after stopping of 45-day injection of fondaparinux. There were no complications in the area of intervention and bleedings.

The incidence, risk factors, characteristics, and prognosis of recurrent deep venous thrombosis in the contralateral lower extremity

BACKGROUND

Recurrent events after a first symptomatic deep venous thrombosis (DVT) are relatively frequent, but little is known about contralateral recurrent DVT (RDVT).

METHODS

We retrospectively reviewed the medical records of patients with a first symptomatic lower extremity DVT between January 2017 and April 2021. The incidence, demographics, risk factors, and prognosis of RDVT were analyzed, with differences compared between patients with contralateral RDVT and those with ipsilateral RDVT.

RESULTS

In 570 consecutive patients with DVT, 28 patients (4.91%) developed contralateral RDVT, and 49 patients (8.60%) developed ipsilateral RDVT during a mean follow-up of 27.62 ± 14.84 months. Contralateral RDVT was more frequently found in the right lower extremity, whereas ipsilateral RDVT had more left lower extremity involvement. The median follow-up was 12 months until ipsilateral RDVT and 26.5 months until contralateral RDVT. In multivariate Cox analysis, inherited thrombophilia, stent extension with 50% to 100% coverage, autoimmune disease and anticoagulation noncompliance were identified as risk factors for contralateral RDVT. During follow-up, 5 patients (17.86%) with contralateral RDVT and 10 patients (20.41%) with ipsilateral RDVT died (P > .05), with 12 of 15 dying of an underlying malignancy.

CONCLUSIONS

The incidence of contralateral RDVT after a first symptomatic DVT is relatively low, and contralateral DVT is strongly associated with stent extension with 50% to 100% coverage, autoimmune disease, anticoagulation noncompliance, and inherited thrombophilia. Compared with ipsilateral RDVT, contralateral RDVT occurs later and is more often in the right lower extremity. Survival following contralateral RDVT is similar to survival following ipsilateral RDVT, with underlying malignancy being the leading cause of death.

Antikoagulation bei Thrombose und Lungenembolie

In diesem Artikel werden aktuelle Evidenz und Leitlinienempfehlungen zur Antikoagulation (AK) bei tiefer Venenthrombose (TVT) und Lungenembolie (LE) zusammengefasst. Bei LE leitet die Stratifizierung bezüglich Frühletalität das weitere Management. Die Messung von Laktat kann hierfür hilfreich sein. Die initiale AK erfolgt intensiviert entweder parenteral oder mit erhöhter Dosis von Apixaban oder Rivaroxaban. Alle Patienten sollten eine Erhaltungstherapie von 3 – 6 Monaten erhalten, da bei AK unter 3 Monaten ein hohes Rezidivrisiko besteht. Die Dauer der anschließenden Sekundärprophylaxe richtet sich nach dem mutmaßlichen VTE-Rezidivrisiko einerseits und dem Blutungsrisiko andererseits. Bei Adipositas bis 150 kg werden Standarddosen von Rivaroxaban und Apixaban als geeignet vorgeschlagen. Bei der krebsassoziierten Thromboembolie wird die bisherige Leitlinienempfehlung für niedermolekulare Heparine (NMH) über 3 – 6 Monate ergänzt durch die Empfehlung für Xa-Inhibitoren, allerdings mit Vorsicht bei gastrointestinalen und urothelialen Tumoren oder erwarteten Wechselwirkungen. Hier und in instabilen Phasen wird NMH bevorzugt.

Low-molecular-weight heparin beyond 12 months in patients with cancer-associated thrombosis

BACKGROUND

Clinical guidelines indicate that in patients with cancer-associated thrombosis (CAT), anticoagulant treatment should be continued beyond 6 months as long as the cancer is active. We aimed to analyse the safety of low-molecular-weight heparin (LMWH) beyond 12 months in patients with CAT.

METHODS

We performed a post hoc analysis of consecutive CAT patients from October 2008 to December 2019. The primary outcome was the rate of clinically relevant bleeding (CRB), and we compared two periods (1-12 vs. 12-24 months). Hazard ratio (HR), competing risk analysis and sensitivity analyses were performed.

RESULTS

Of the 588 patients included, 30.1% (n = 177) received LMWH beyond 12 months. The rate of CRB in the first 12 months compared to the 12-24 month period was 3.2 per 100 patients/month (95% CI 2.5-4.1) vs. 0.9 per 100 patients/month (95% CI 0.4-1.5), (P < 0.0001). The competing risk analysis of CRB comparing both periods showed a lower sub-distribution hazard ratio (SHR) during the period 12-24 months (SHR: 0.5, 95% CI: 0.3-0.8, P < 0.001).

CONCLUSION

In patients with cancer-associated thrombosis under anticoagulant treatment with LMWH, the rate of clinically relevant bleeding and major bleeding were lower beyond 12 months.

Rivaroxaban treatment for six weeks versus three months in patients with symptomatic isolated distal deep vein thrombosis: randomised controlled trial

OBJECTIVE

To compare two different treatment durations of rivaroxaban in patients with symptomatic isolated distal deep vein thrombosis (DVT).

DESIGN

Randomised, double blind, placebo controlled clinical trial.

SETTING

28 outpatient clinics specialising in venous thromboembolism.

PARTICIPANTS

402 adults (≥18 years) with symptomatic isolated distal DVT.

INTERVENTIONS

After receiving standard dose rivaroxaban for six weeks, participants were randomly assigned to receive rivaroxaban 20 mg or placebo once daily for an additional six weeks. Follow-up was for 24 months from study inclusion.

MAIN OUTCOMES MEASURES

The primary efficacy outcome was recurrent venous thromboembolism during follow-up after randomisation, defined as the composite of progression of isolated distal DVT, recurrent isolated distal DVT, proximal DVT, symptomatic pulmonary embolism, or fatal pulmonary embolism. The primary safety outcome was major bleeding after randomisation until two days from the last dose of rivaroxaban or placebo. An independent committee adjudicated the outcomes.

RESULTS

200 adults were randomised to receive additional rivaroxaban treatment and 202 to receive placebo. Isolated distal DVT was unprovoked in 81 (40%) and 86 (43%) patients, respectively. The primary efficacy outcome occurred in 23 (11%) patients in the rivaroxaban arm and 39 (19%) in the placebo arm (relative risk 0.59, 95% confidence interval 0.36 to 0.95; P=0.03, number needed to treat 13, 95% confidence interval 7 to 126). Recurrent isolated distal DVT occurred in 16 (8%) patients in the rivaroxaban arm and 31 (15%) in the placebo arm (P=0.02). Proximal DVT or pulmonary embolism occurred in seven (3%) patients in the rivaroxaban arm and eight (4%) in the placebo arm (P=0.80). No major bleeding events occurred.

CONCLUSIONS

Rivaroxaban administered for six additional weeks in patients with isolated distal DVT who had an uneventful six week treatment course reduces the risk of recurrent venous thromboembolism, mainly recurrent isolated distal DVT, over a two year follow-up without increasing the risk of haemorrhage.

TRIAL REGISTRATION

EudraCT 2016-000958-36; ClinicalTrials.gov NCT02722447.