D-dimer levels correlate with pathologic thrombosis in trauma patients

Deep Vein Thrombosis in Patients with Intertrochanteric Fracture: A Retrospective Study

BACKGROUND

This study aimed to investigate the incidences of pre- and post-operative lower extremity deep venous thrombosis (DVT) in hospitalized patients with intertrochanteric fractures and to analyze the relevant risk factors.

METHODS

A retrospective study was conducted between July 2014 and October 2016 in 218 intertrochanteric fracture patients who presented at Xi'an Honghui Hospital and underwent Doppler ultrasonography for DVT diagnosis. We divided DVT into distal, proximal, and mixed thrombosis. Patients were divided into either the thrombosis or no thrombosis group according to preoperative and postoperative ultrasonography results. All patients were evaluated for the risk factors associated with thrombosis.

RESULTS

A total of 37.61% of preoperative patients had DVT, and the postoperative incidence increased to 58.72%. The days between fracture and hospitalization and the days between fracture and surgery were independent risk factors for preoperative DVT. The days between fracture and hospitalization and d-dimer levels at postoperative 1 day were independent risk factors of postoperative DVT. In total 23.4% of the patients progressed from having no thrombosis preoperatively to having distal, proximal, or mixed DVT postoperatively (22.02%, 0.46%, and 0.92%, respectively). Distal DVT constituted 86.59% and 90.63% of all preoperative and postoperative DVTs, respectively.

CONCLUSION

Intertrochanteric fracture is a common type of hip fracture in the elderly, and the incidence of DVT after intertrochanteric fracture may be underestimated. Early intervention (early admission and early surgery) might reduce the incidence of DVT.

Hypercoagulability after trauma: hemostatic changes and relationship to venous thromboembolism

BACKGROUND

Major trauma induces a hypercoagulable state, which is frequently complicated by pathological thrombosis. However the sequential changes in coagulation markers and their relationship to clinical thrombosis have been poorly characterized.

METHODS

We measured several markers of in vivo coagulation and fibrinolysis and their regulation serially for 2 weeks after multi-system trauma in a prospective cohort of patients who received no anticoagulant prophylaxis. Asymptomatic deep vein thrombosis (DVT) was assessed by routine bilateral venography between day 12 and 14. Clinically suspected DVT and pulmonary embolism (PE) were investigated in a standardized manner.

RESULTS

Among the 135 cohort patients the overall venous thromboembolism (VTE) rate was 59%. Markers of thrombin generation were markedly increased within 24 hours of injury, remained persistently elevated for about 5 days and then decreased by day 14. No early compensatory increase in Tissue Factor Pathway Inhibitor (TFPI) or the complex of Factor Xa and TFPI (FXa-TFPI) was seen; FXa-TFPI remained depressed throughout the study. There was no inverse relationship demonstrated between markers of thrombin generation and thrombin regulation. Acquired APC resistance and hypofibrinolysis did not appear to be important contributors to hypercoagulability after trauma. None of the coagulation markers were independently predictive of VTE. Increasing age was the only significant, independent predictor of VTE.

CONCLUSION

Major trauma leads to significantly increased and persistent thrombin generation with disruption of its regulation. Coagulation markers do not appear to add independent predictive value in detecting VTE. Increasing age is the most important clinical predictor of VTE after trauma.

Venous thromboembolism in trauma: an update for the intensive care unit practitioner

Venous thromboembolism (VTE) in trauma patients is a capricious problem that continues to plague trauma surgeons and critical care physicians alike. Pharmacologic preventions of VTE with anticoagulants are often contraindicated in the trauma patient because of risk of bleeding diathesis. Mechanical prophylaxis in the form of venous compression boots often cannot be placed because of external fixators, swelling, and so forth. Providing effective VTE prophylaxis, while at the same time providing definitive care for the trauma patient, can be a nightmare. This review will first discuss the incidence and prevalence of VTE, as well as investigate the condition's diagnosis and treatment. Solutions to frequently encountered clinical dilemmas in managing VTE in trauma patients are considered in the form of frequently asked questions. Diagnostic techniques such as magnetic resonance venography, D-dimer, and various computed tomography methods are evaluated. Recent literature on preventive pharmacologic therapies is explored. The authors also consider whether vena cava filters prevent pulmonary embolism in trauma patients.

A role for interleukin-10 in the assessment of venous thromboembolism risk in injured patients

BACKGROUND

Management of patients with multiple trauma requires prophylaxis for venous thromboembolism (VTE). This involves recognition of the physiologic factors that are associated with VTE risk. Currently, there is no effective strategy for risk assessment. The purpose of this study is to investigate the relationship of serum P-selectin and interleuken-10 (IL-10) with VTE as a possible physiologic marker.

METHODS

Patients admitted to two trauma centers with an Injury Severity Score >/=9 had blood samples drawn and underwent duplex ultrasound scanning of the lower extremities before initiating prophylaxis at admission, on days 3 and 7, and weekly until discharge. Patients were prophylaxed according to institutional protocols.

RESULTS

One hundred eighty-six patients were enrolled with a VTE incidence of 17.8%. The population was predominantly male (60%), with a mean age of 48 years. sP-selectin levels were not statistically different between the groups (64.4 versus 74.8 pg/mL). However, IL-10 was significantly lower in the VTE group at both the initial and subsequent blood draws (21 versus 165 ng/mL, p = 0.012). Further, the ratio of sP-selectin to IL-10 (3.92 versus 0.92, p = 0.014) was statistically higher in the VTE group at admission.

CONCLUSION

An elevated sP-selectin to IL-10 ratio appears to be associated with the development of VTE in patients at high risk and may prove to be a useful clinical marker for this dreaded complication among trauma patients. Early recognition of this high-risk group improves the accuracy of the risk/benefit determination for prophylaxis and identifies a group in whom routine ultrasound screening would be cost-effective.

Coagulopathy and the role of recombinant human activated protein C in sepsis and following polytrauma

Recombinant human activated protein C (rhAPC) also known as drotrecogin alfa (activated) has known antithrombotic, anti-inflammatory, and profibrinolytic properties in severe sepsis. Treatment with rhAPC (Xigris) has been shown to reduce mortality in patients with severe sepsis. The lack of any trials of rhAPC in trauma patients means that a definitive recommendation regarding its use in the polytraumatised patient, in whom severe head trauma or other contraindications for the use of rhAPC have been excluded remains controversial at present. This article describes the current evidence of its efficacy and safety in severe sepsis with relation to surgery and trauma.

Damage control surgery and intensive care

The introduction and establishment of the 'damage control surgery' concept has led to increasing numbers of severely injured and unstable patients being presented to Intensive Care Units (ICU) for ongoing resuscitation. These patients present many challenges for the Intensive Care team and emphasise the need for a multidisciplinary approach to optimise trauma patient management. Multiple issues need to be addressed simultaneously while the overall aim is to rapidly achieve a physiological environment that will allow the best possible recovery. The 'lethal triad' of hypothermia, acidosis, and coagulopathy due to initial hypovolaemia require aggressive correction. From the outset ICU management must also attempt to minimise the complications of these injuries and the resuscitative process. This review will address some of the key issues relating to the care of these patients in the ICU.

Acute complications associated with greenfield filter insertion in high-risk trauma patients

BACKGROUND

Use of Greenfield filters (GFs) to prevent fatal pulmonary embolism (PE) in trauma patients is generally well accepted. Nonetheless, a surprisingly small number of trauma surgeons insert filters in their patients. Among the reasons cited is fear of complications.

METHODS

We observed three femoral arteriovenous fistulae (AVF) in trauma patients who had inferior vena caval placement of filters for PE prophylaxis in one 12-month period (academic year 1999). In an effort to document the magnitude of this problem, we evaluated trauma patients who had a GF inserted in academic year 2000.

RESULTS

During that year, 133 consecutive patients (8.6% of trauma admissions) received 133 GFs through a percutaneous approach. The most common isolated indications for GF insertion included closed head injuries (n = 28), multiple long bone fractures (n = 27), pelvic and acetabular fractures (n = 6), spinal cord injuries (n = 16), and vertebral fractures (n = 3). Five patients had documented deep venous thrombosis (DVT) diagnosed by duplex ultrasonography before GF placement, and 11 patients had other indications requiring a filter. There were 37 patients with more than one indication requiring filter placement. Most patients (57%) underwent preinsertion duplex scanning of their lower extremity veins; 77% of patients underwent postinsertion scanning. Filters were inserted an average of 6.8 +/- 0.6 (SE) days after trauma. No AVF were suspected clinically or detected ultrasonographically. No operative or postoperative complications occurred. DVT was observed in 30% of patients despite 92% prophylaxis; there was a 26% incidence of de novo thrombi detected. None of the patients evidenced DVT clinically.

CONCLUSION

Our data indicate that complications of GF insertion for prophylaxis against PE from DVT complicating trauma patients continue to be negligible. In addition, the incidence of insertion-site thrombosis may be lower than expected. Moreover, femoral AVF is a rare complication of this procedure.

Venous thromboembolism in trauma: a local manifestation of systemic hypercoagulability?

BACKGROUND

The purpose of this study was to evaluate the relative importance of systemic hypercoagulability, preexisting and acquired risk factors, and specific injury patterns in the development of venous thromboembolism (VTE) after injury.

METHODS

Injured patients with an Injury Severity Score > or = 15 were followed with lower extremity venous duplex ultrasonography, prothrombin fragment 1 + 2, and quantitative D-dimer levels at 1 and 3 days and then weekly until discharge.

RESULTS

Among 101 patients with a mean Injury Severity Score of 27.3 +/- 10.5 followed for 12.4 +/- 8.7 days, 28 (27.7%) developed a lower extremity thrombosis, 2 (1.9%) sustained a pulmonary embolism, and 1 (0.9%) had a symptomatic upper extremity thrombosis. Although admission fragment 1 + 2 and D-dimer levels were elevated in 81.4% and 100% of patients, respectively, mean levels were not significantly different in those with or without VTE. VTE was more common (p < 0.05) among those with obesity, age > 40 years, immobilization for > 3 days, spine fractures, and lower extremity fractures. However, only obesity (p = 0.004) and immobilization > 3 days (p = 0.05) were independent predictors of VTE in a multivariate analysis.

CONCLUSION

Although elevated in seriously injured patients, neither markers of activated coagulation nor specific injury patterns are predictive of VTE. Associations with immobilization and obesity suggest that VTE after injury is a systemic hypercoagulable disorder with local manifestations of thrombosis related to lower extremity stasis.

Incidence and natural history of below-knee deep venous thrombosis in high-risk trauma patients

BACKGROUND

Venous thromboembolic disease remains a difficult problem in the trauma patient population. The purpose of this study was to delineate the incidence and natural history of below-knee deep venous thrombosis (BKDVT) in high-risk trauma patients.

METHODS

Patients were stratified into risk categories (low, high, or very high) for deep venous thrombosis on the basis of an institutional practice management guideline and known risk factors. All at-risk patients received either sequential compression devices (SCDs) or subcutaneous heparin (SQH) compounds, and high-risk patients also underwent weekly surveillance by duplex scanning. Very-high-risk patients had prophylactic inferior vena cava (IVC) filter placement. This prospective, observational study examines the duplex results on all high-risk patients. Data regarding method of prophylaxis, the incidence of proximal propagation on serial duplex examinations, and changes in management (anticoagulation or IVC filter placement) were collected on the high-risk patients who developed a BKDVT.

RESULTS

Between March 1997 and June 2001, 601 patients were stratified into the high-risk category and underwent a total of 1,109 duplex examinations. Eighty-five patients (14.1%) had 113 BKDVTs. These patients underwent a total of 212 duplex examinations; all patients developed their BKDVTs within 34 days. Weekly incidence was 40 (47.1%), 25 (29.4%), 15 (17.6%), 1 (1.2%), and 4 (4.7%) for weeks 1 through 5, respectively. SCDs, SQH compounds, and SCDs with SQH compounds were used on 73, 3, and 9 patients, respectively. In 4 of 85 (4.7%) patients, the BKDVT propagated proximally to an above-knee location in 4 to 8 days. Two of these patients were anticoagulated, and two underwent placement of an IVC filter. One patient (1.2%) with a BKDVT that had not propagated on duplex study developed a pulmonary embolus.

CONCLUSION

Patients identified as high-risk by our practice management guideline had a 14.1% incidence of a BKDVT; 94.1% were diagnosed within the first 3 weeks of hospitalization. Proximal propagation occurred in 4.7% and led to changes in management. Serial duplex examination of the BKDVT alone, rather than systemic anticoagulation or IVC filter placement, appears to be a reasonable treatment alternative.

Physical examination findings in deep venous thrombosis

DVT is a potentially serious disease and can serve as a marker for PE, an entity with even higher morbidity. Thus, it is critically important that emergency physicians consider this diagnosis in patients who present with suspicious symptoms. Recognition of alternative conditions, such as compartment syndrome, septic arthritis, and cellulitis, is also important for optimal care. Because physical examination is only 30% accurate for DVT, it serves to increase clinical suspicion in patients at risk but cannot be used to eliminate the possibility of thromboembolic disease. Because of this limitation, the diagnosis of DVT should be pursued using adjunctive testing in any patient with unexplained limb pain or swelling. Duplex sonography is currently the initial diagnostic study of choice for evaluation of DVT and, if test results are negative, it should be repeated serially if the clinical suspicion is high.

Thrombosis risk in the trauma patient. Prevention and treatment

Hypercoagulability is frequently seen in the trauma patients. Debate continues over the best method of prophylaxis, diagnosis, and treatment for the trauma patient. From experience with orthopedic and general surgery patients, much has been learned about prophylaxis and diagnosis, and as treatment protocols have been taken from internal medicine literature. Universal guidelines relating specifically to the trauma patient have not, however, been established. Overall, most of the literature suggests using LMWH for the prophylaxis of trauma patients. When LMWH is contraindicated, SCD should be used, with AVFP as a second choice. Surveillance screening for DVT remains controversial, but surveillance before transfer to extended care facilities has proven beneficial. Finally, when DVT is diagnosed, treatment should be initiated as soon as possible and should be continued until the DVT has resolved. Long-term anticoagulation therapy or use of caval filters may be necessary to prevent the morbidity of PE or thrombophlebitic syndrome.

Course of molecular hemostatic markers during and after different surgical procedures

STUDY OBJECTIVE

To establish the most vulnerable time of thrombi formation with regard to the plasmatic (noncellular) part of the coagulatory and fibrinolytic systems.

DESIGN

Nonrandomized observational study.

SETTING

A surgical and an orthopedic unit and the central laboratory of a university hospital.

PATIENTS

61 consenting ASA physical status I and II inpatients undergoing four different types of surgery: total hip replacement (THR): 16 patients; hemicolectomy: 15 patients; endoscopic cholecystectomy: 15 patients; subtotal thyroid resection: 15 patients.

INTERVENTIONS

The time course of 11 procoagulatory and fibrinolytic parameters was examined during the different types of surgery. Blood samples were drawn on the day before surgery, directly before the induction of general anesthesia, 1 to 2 hours postoperatively, and on the mornings of postoperative days 1, 2, 3, 4, and 5.

MEASUREMENTS AND MAIN RESULTS

The coagulation samples were centrifuged within 1 hour of collection at 2,300 g for 15 minutes at 4 degrees C. Hemoglobin, hematocrit, platelets, fibrinogen, prothrombin time, activated partial thromboplastin time, thrombin time, antithrombin III, and protein C were determined immediately on laboratory arrival of the samples. The samples were aliquoted at -70 degrees C. They were thawed within 2 weeks and prepared for the following assays: thrombin-antithrombin III complexes (TAT-complexes), D-dimers, and plasminogen activator inhibitor type 1. Maximum activation of coagulation is not reached until 2 hours postoperatively and slowly decreases until normal values are reached around the fifth postoperative day. Parameters displaying the greatest changes are TAT-complexes and D-dimers. The type of surgery with the most pronounced changes was total hip replacement, followed by hemicolectomy, cholecystectomy, and subtotal thyroid resection.

CONCLUSION

The total hip replacement and hemicolectomy groups show similar and strong activation of the procoagulatory and fibrinolytic systems. Much less pronounced are the changes during endoscopic cholecystectomy and subtotal thyroid resection. Maximum activation occurs 1 to 2 hours postoperatively.

Contrasting post-traumatic serial changes for D-dimer and PAI-1 in critically injured patients

We measured D-dimer and plasminogen activator inhibitor-1 (PAI-1) activity in 45 trauma patients to assess their efficacy in predicting the post-traumatic hemostatic perturbations. We found the correlation between D-dimer measured by Simpli Red test and ELISA to be highly significant (p=0.0001). The D-dimer ELISA indicated that the serial changes of D-dimer after trauma were variable. However, the increases of D-dimer were associated with clinical conditions of the patient, such as trauma surgery, infections, or thrombotic complications. A significant correlation was found for D-dimer levels measured by ELISA versus the injury severity score (ISS) in all the trauma patients on day 1 (p=0.0153) and on day 2 (p=0.0495). The PAI-1 activity was increased at admission and showed a progessive decline from day 2 onward, and the correlation for the daily decline of PAI-1 was highly significant (p=0.0001). The PAI-1 activity and plasminogen activator activity showed a significant negative correlation on days 1, 2, and 3. PAI-1 activity correlated moderately with D-dimer level only on day 1 (p=0.0569). Three out of forty-five patients developed thrombotic complications: one patient who died from pulmonary embolism and two patients who developed adult respiratory distress syndrome (ARDS). In summary: 1) PAI-1 activity and D-dimer exhibited contrasting serial changes after trauma. 2) There was also a negative correlation between PAI-1 activity and PA activity. 3) A significant correlation of D-dimer with ISS confirms, as might be anticipated, that there is increased activation of the coagulation mechanism in severe injury, and suggests that D-dimer levels may prove useful to screen for patients at strong risks of thrombotic complications.

Prevention and treatment of venous thromboembolism after major trauma

In prospective studies the incidence of deep venous thrombosis, documented by venography, is between 35% and 63% in patients with major trauma. Five independent risk factors for deep vein thrombosis have been identified in these patients: older age, fracture of the femur or tibia, surgery, spinal cord injury and blood transfusion. Mechanical antithrombotic methods and low-dose unfractionated heparin administered subcutaneously moderately decrease the risk of venous thromboembolism but are less effective than a fixed dose of subcutaneous unmonitored low molecular weight heparin. Prophylaxis with oral anticoagulants (International Normalized Ratio 2.0-3.0) is also effective but is much less used because of the bleeding risk. This is particularly the case in patients with intracranial neurosurgery and acute spinal cord injury. Only a few clinical studies have evaluated the treatment of venous thromboembolism in patients with major trauma. If the condition of a patient with major injury allows, the treatment of venous thromboembolism recommended after hip replacement is cautiously applied.

The damage control sequence and underlying logic

With the growing understanding of the pathophysiology of exsanguination has come the evolution of extraordinary surgical techniques designed to improve survival. As the success of damage control has grown, so has its acceptance in the traditional surgical community. Our challenge now is to scientifically define patient selection, refine intraoperative techniques, and acquire a greater clinical and basic science understanding of the physiology of exsanguination and reperfusion injury in resuscitation. In these efforts, overall survival should continue to increase and morbidity should continue to decrease.

Venous thromboembolism in the high-risk trauma patient: do risks justify aggressive screening and prophylaxis?

OBJECTIVE

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are considered to be a major source of morbidity and mortality among trauma patients. Several reports have identified high-risk patients with recommendations for management ranging from frequent duplex scanning to placement of prophylactic inferior vena cava (IVC) filters. We reviewed our experience with a large trauma population to determine whether such approaches are justified.

METHODS

We analyzed 2,868 consecutive trauma admissions over 22 months and identified 280 patients (10%) in high-risk groups who survived > or = 48 hours: (1) severe closed head injury with mechanical ventilation > or = 72 hours, (2) closed head injury with lower extremity fractures, (3) spinal column/cord injury, (4) combined pelvic and lower extremity fractures, and (5) major infrarenal venous injuries. The remaining nonthermal injury patients constituted the low-risk group.

RESULTS

There were 280 high-risk patients, 213 of whom (76%) received prophylaxis with compression therapy. There were 12 cases of DVT (5%) with four nonfatal PE (1.4%). Six patients (2%) had therapeutic IVC filters inserted and only one patient had prophylactic placement. There were 38 deaths in this group, attributable primarily to severe closed head injury or spine injuries, and none were caused by PE. In the 2,249 low-risk patients, there were three cases of DVT (0.1%, p < 0.05 vs. high risk) and no PE (p < 0.05 vs. high risk).

CONCLUSIONS

Although these patients were at increased risk for thromboembolic events, the overall incidence of DVT was still extremely low with no apparent PE deaths. In our patient population, aggressive screening and prophylactic IVC filters would not have benefited 95% of "high-risk" patients without DVT and would not have prevented any deaths. We could not identify any population, except perhaps venous injuries, where such expensive and potentially harmful maneuvers seemed justified. Our experience with DVT and PE does not support either aggressive screening or prophylactic IVC filters as the standards of care.

Use of low molecular weight heparin in preventing thromboembolism in trauma patients

OBJECTIVE

To investigate the safety and effectiveness of low molecular weight heparin (LMWH) in preventing deep venous thrombosis (DVT) in high-risk trauma patients, compared with mechanical methods of prophylaxis.

DESIGN

A prospective randomized trial conducted over a 19-month period in an urban, academic trauma center.

METHODS

All trauma patients with the following risk factors for the development of DVT were considered for enrollment in this study: any injury with an Abbreviated Injury Scale score > or = 3; major head injury (Glasgow Coma Scale score < or = 8); spine, pelvic, or lower extremity fractures; acute venous injury; or age > 50 years. After a screening venous duplex examination, the patients were assigned to a Heparin versus No-Heparin group, depending upon the presence of injuries precluding the use of heparin. In the Heparin group, the patients were then randomized to receive either LMWH or optimal mechanical compression (defined as bilateral sequential gradient pneumatic compression (SCD) or, in the presence of lower extremity injuries precluding the use of the SCD, the arteriovenous impulse (AVI) compression system). All the patients in the No-Heparin group received optimal compression. Enrolled patients underwent sequential duplex examinations every 5 to 7 days until discharge.

RESULTS

Of the 487 consecutive patients initially enrolled in this study, 372 were available for at least the first two duplex examinations and comprise the study population. Only nine (2.4%) patients developed DVT, compared with the predicted 9.1% rate in high-risk trauma patients receiving no prophylaxis (p = 0.037). Of the 120 patients who were randomized to receive LMWH, only one (0.8%) developed DVT. In the SCD group, there were 5 of 199 patients (2.5%) with DVT, and 3 of 53 (5.7%) in the AVI group. One patient with DVT also had clinical symptoms of pulmonary embolism, but there were no deaths secondary to pulmonary embolism. There was one major bleeding complication potentially associated with the use of LMWH.

CONCLUSIONS

The administration of LMWH is a safe and extremely effective method of preventing DVT in high-risk trauma patients. When heparin is contraindicated, aggressive attempts at mechanical compression are warranted.

Effect of critical injury on plasma antithrombin activity: low antithrombin levels are associated with thromboembolic complications

OBJECTIVE

Determine whether severe injury results in decreased plasma antithrombin (AT) activity and whether this decreased AT activity is associated with thromboembolic complications.

DESIGN

Prospective observational.

SUBJECTS

A total of 157 critically injured trauma patients.

METHODS

Each patient underwent laboratory analysis on arrival to the emergency room at hours 8, 16, 24, and 48, and days 3, 4, 5, and 6. Laboratory analyses included AT, tissue factor pathway inhibitor, protein C, prothrombin fragment 1.2, thrombin-antithrombin complex, and D-dimer. Patients were followed for thromboembolic complications including: deep venous thrombosis (DVT), pulmonary embolus, disseminated intravascular coagulation (DIC) and adult respiratory distress syndrome (ARDS).

RESULTS

Mean Injury Severity Score was 23 (+/-11). AT activity fell below normal in 95 (61%) patients; AT activity rose to greater than normal in 51 (32%) patients. Nine (6%) patients developed DVT, two (1%) pulmonary embolus, 13 (8%) DIC and 26 (17%) ARDS. Using logistic regression analysis, low AT levels were a significant predictor of DVT, DIC, and ARDS (p < 0.05). Supranormal At levels were associated with closed head injury (p < 0.05). D-dimer levels were inversely correlated with AT (p < 0.05).

CONCLUSIONS

AT activity was depressed in critically injured patients. Patients with head injury developed supranormal AT activity. The risk factors for AT deficiency mimicked those for thromboembolism. Patients with decreased AT activity were at increased risk for thromboembolic complications. Given heparin's dependence on AT, these data call into question the use of unmonitored heparin thromboembolism prophylaxis.

Posttraumatic Budd-Chiari syndrome treated with thrombolytic therapy and angioplasty

Injury of the hepatic veins or suprahepatic inferior vena cava is a rare cause of Budd-Chiari syndrome. Treatment of this syndrome has primarily involved hepatic venous decompression with a variety of portosystemic shunts. We report a case of thrombosis of the inferior vena cava after blunt injury managed with interventional radiologic techniques.

Venous thromboembolism in trauma patients

Venous thromboembolism is common in patients with multiple injuries. In addition to having endothelial injury, trauma patients are hypercoagulable and are often confined to bed, thus placing them at high risk for venous thromboembolic events. Duplex ultrasonography and impedance plethysmography are the most practical modalities to screen trauma patients for the presence of DVT. At present, there do not appear to be any effective means of preventing DVT in trauma patients, although low molecular weight heparin appears promising. In particularly high-risk patients vena cava filters have been used safely and effectively to prevent PE.