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Righini M, Robert-Ebadi H. Management of isolated distal deep vein thrombosis. VASA 2024; 53:185-192. [PMID: 38546285 DOI: 10.1024/0301-1526/a001119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
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.
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Affiliation(s)
- Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
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Galanaud JP, Trujillo-Santos J, Bikdeli B, Bertoletti L, Di Micco P, Poénou G, Falgá C, Zdraveska M, Lima J, Rivera-Civico F, Muixi JF, Monreal M. Clinical Presentation and Outcomes of Patients With Cancer-Associated Isolated Distal Deep Vein Thrombosis. J Clin Oncol 2024; 42:529-537. [PMID: 37471683 DOI: 10.1200/jco.23.00429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/26/2023] [Accepted: 05/23/2023] [Indexed: 07/22/2023] Open
Abstract
PURPOSE Patients with isolated distal deep vein thrombosis (DVT) have lower rates of adverse outcomes (death, venous thromboembolism [VTE] recurrence or major bleeding) than those with proximal DVT. It is uncertain if such findings are also observed in patients with cancer. METHODS Using data from the international Registro Informatizado de la Enfermedad TromboEmbolica venosa registry, we compared the risks of adverse outcomes at 90 days (adjusted odds ratio [aOR]; 95% CI) and 1 year (adjusted hazard ratio [aHR; 95% CI]) in 886 patients with cancer-associated distal DVT versus 5,196 patients with cancer-associated proximal DVT and 5,974 patients with non-cancer-associated distal DVT. RESULTS More than 90% of patients in each group were treated with anticoagulants for at least 90 days. At 90 days, the adjusted risks of death, VTE recurrence, or major bleeding were lower in patients with non-cancer-associated distal DVT than in patients with cancer-associated distal DVT (reference): aOR = 0.16 (0.11-0.22), aOR = 0.34 (0.22-0.54), and aOR = 0.47 (0.27-0.80), respectively. The results were similar at 1-year follow-up: aHR = 0.12 (0.09-0.15), aHR = 0.39 (0.28-0.55), and aHR = 0.51 (0.32-0.82), respectively. Risks of death, VTE recurrence, and major bleeding were not statistically different between patients with cancer-associated proximal versus distal DVT, both at 90 days: aOR = 1.11 (0.91-1.36), aOR = 1.10 (0.76-1.62), and aOR = 1.18 (0.76-1.83), respectively, and 1 year: aHR = 1.01 (0.89-1.15), aHR = 1.02 (0.76-1.35), and aHR = 1.10 (0.76-1.61), respectively. However, more patients with cancer-associated proximal DVT, compared with cancer-associated distal DVT, developed fatal pulmonary embolism (PE) during follow-up: The risk difference was 0.40% (95% CI, 0.23 to 0.58). CONCLUSION Cancer-associated distal DVT has serious and relatively comparable outcomes compared with cancer-associated proximal DVT. The lower risk of fatal PE from cancer-associated distal DVT needs further investigation.
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Affiliation(s)
- Jean-Philippe Galanaud
- Department of Medicine, Sunnybrook Heath Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Javier Trujillo-Santos
- Department of Internal Medicine, Hospital General Universitario Santa Lucía, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT
- Cardiovascular Research Foundation (CRF), New York, NY
| | - Laurent Bertoletti
- Department of Vascular Medicine and Therapeutics, Hôpital Nord-CHU St-Etienne, Saint-Etienne, France
| | - Pierpaolo Di Micco
- Department of Internal Medicine and Emergency Room, Ospedale Buon Consiglio Fate bene fratelli, Naples, Italy
| | - Géraldine Poénou
- Department of Vascular Medicine and Therapeutics, Hôpital Nord-CHU St-Etienne, Saint-Etienne, France
| | - Conxita Falgá
- Department of Internal Medicine, Hospital de Mataró, Barcelona, Spain
| | - Marija Zdraveska
- University Clinic of Pneumology and Allergy Skopje, Skopje, Republic of Macedonia
| | - Jorge Lima
- Department of Pneumonology, Hospital Universitario Virgen de Valme, Sevilla, Spain
| | | | | | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM-Universidad Católica San Antonio de Murcia, Murcia, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
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Kay AB, Morris DS, Woller SC, Collingridge DS, Majercik S. Below the knee, let it be: Management of calf DVT in hospitalized trauma patients. Am J Surg 2023; 226:891-895. [PMID: 37574336 DOI: 10.1016/j.amjsurg.2023.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Management of below-knee DVT (BKDVT) in trauma patients is uncertain. We hypothesized that BKDVT can be managed with observation only. METHODS Secondary analysis on trauma inpatients March 2017-September 2019 with risk assessment profile ≥5. Management of BKDVT included observation with ultrasound. BKDVT was compared to above-knee DVT (AKDVT), and BKDVT with progression to AKDVT/PE compared to no progression. RESULTS Of 1988 patients, 136 (6.8%) BKDVT and 23 (1.2%) AKDVT. 7 (6.9%) BKDVT progressed to AKDVT/PE. 6.9% had BKDVT progression, associated with higher ISS (36.7 vs 21.6, p = 0.005), longer prophylaxis delay (121 vs 45 h, p = 0.02) and longer hospital LOS (25.6 vs 7.8, p = 0.01). None experienced post-thrombotic syndrome. CONCLUSION Majority of BKDVT in hospitalized trauma patients did not progress to AKDVT. Observation for progression, rather than treatment, was not associated with increased PE risk or thrombotic sequelae. Observation with serial ultrasound may serve as a practical alternative to anticoagulation in trauma patients with BKDVT.
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Affiliation(s)
- Annika Bickford Kay
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT, USA.
| | - David S Morris
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT, USA.
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Murray, UT, USA; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | | | - Sarah Majercik
- Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, UT, USA.
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Jørgensen CT, Tavoly M, Førsund E, Pettersen HH, Tjønnfjord E, Ghanima W, Brækkan SK. Incidence of bleeding and recurrence in isolated distal deep vein thrombosis: findings from the Venous Thrombosis Registry in Østfold Hospital. J Thromb Haemost 2023; 21:2824-2832. [PMID: 37394122 DOI: 10.1016/j.jtha.2023.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/05/2023] [Accepted: 06/22/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Isolated distal deep vein thrombosis (IDDVT) is a common presentation of deep vein thrombosis. There are limited data on the long-term risk of recurrence after IDDVT. OBJECTIVES We aimed to determine the short- and long-term incidence of venous thrombosis (VTE) recurrence after cessation of anticoagulation and the 3-month incidence of bleeding during anticoagulant treatment in patients with IDDVT. METHODS Between January 2005 and May 2020, 475 patients with IDDVT and without active cancer were identified from the Venous Thrombosis Registry in Østfold Hospital, which is an ongoing registry of consecutive patients with VTE at Østfold Hospital, Norway. Major and clinically relevant, nonmajor bleeding as well as recurrent VTE were registered, and the cumulative incidences of these events were assessed. RESULTS The median age of the patients was 59 years (IQR, 48-72 years), 243 (51%) patients were women, and 175 events (36.8%) were classified as unprovoked. The 1-, 5-, and 10-year cumulative incidences of recurrent VTE were 5.6% (95% CI, 3.7-8.4), 14.7% (95% CI, 11.1-19.4), and 27.2% (95% CI, 21.1-34.5), respectively. The recurrence rates were higher for unprovoked IDDVT than for provoked IDDVT. Among the recurrent events, 18 (29%) were pulmonary embolisms and 21 (33%) were proximal deep vein thromboses. The 3-month cumulative incidence of major bleeding was 1.5% (95% CI, 0.7-3.1) overall and 0.8% (95% CI, 0.2-3.1) when restricted to patients treated with direct oral anticoagulants. CONCLUSION Despite initial treatment, the long-term risk of VTE recurrence after first-time IDDVT is high. The bleeding rates during anticoagulation, particularly with direct oral anticoagulants, were acceptably low.
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Affiliation(s)
- Camilla Tøvik Jørgensen
- Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Mazdak Tavoly
- Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway; Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eli Førsund
- Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway
| | | | - Eirik Tjønnfjord
- Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway
| | - Waleed Ghanima
- Department of Research, Østfold Hospital, Sarpsborg, Norway; Clinic of Internal Medicine, Østfold Hospital Sarpsborg, Sarpsborg, Norway; Department of Hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Sigrid Kufaas Brækkan
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway; Thrombosis Research Center, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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Galanaud JP, Sevestre MA, Pernod G, Vermorel C, Rolland C, Soudet S, Laroche JP, Bosson JL. Isolated distal deep vein thrombosis: What have we learnt from the OPTIMEV study? J Med Vasc 2023; 48:3-10. [PMID: 37120268 DOI: 10.1016/j.jdmv.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/20/2023] [Indexed: 05/01/2023]
Abstract
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.
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Affiliation(s)
- J-P Galanaud
- Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada.
| | - M-A Sevestre
- Department of Vascular Medicine, Amiens University Hospital, Amiens, France
| | - G Pernod
- Department of Vascular Medicine, Grenoble-Alpes University Hospital, Grenoble, France
| | - C Vermorel
- University Grenoble Alpes, CNRS, Department of Public Health, Grenoble-Alpes University Hospital and, TIMC-IMAG, 38000 Grenoble, France
| | - C Rolland
- University Grenoble Alpes, CNRS, Department of Public Health, Grenoble-Alpes University Hospital and, TIMC-IMAG, 38000 Grenoble, France
| | - S Soudet
- Department of Vascular Medicine, Amiens University Hospital, Amiens, France
| | - J-P Laroche
- Vascular Medicine Physician, Private practice office, Avignon, France
| | - J-L Bosson
- University Grenoble Alpes, CNRS, Department of Public Health, Grenoble-Alpes University Hospital and, TIMC-IMAG, 38000 Grenoble, France
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Ageno W, Bertù L, Bucherini E, Camporese G, Dentali F, Iotti M, Lessiani G, Parisi R, Prandoni P, Sartori M, Visonà A, Bigagli E, Palareti G. Rivaroxaban treatment for six weeks versus three months in patients with symptomatic isolated distal deep vein thrombosis: randomised controlled trial. BMJ 2022; 379:e072623. [PMID: 36520715 PMCID: PMC9682494 DOI: 10.1136/bmj-2022-072623] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Walter Ageno
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | - Lorenza Bertù
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | | | - Giuseppe Camporese
- Unit of Angiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | - Matteo Iotti
- Cardiovascular Medicine Unit - AUSL-IRCCS, Reggio Emilia, Italy
| | - Gianfranco Lessiani
- Angiology Unit, Department of Internal Medicine, Villa Serena Hospital, Città Sant'Angelo, Italy
| | - Roberto Parisi
- Department of Medicine, SS Giovanni e Paolo Hospital, Venice, Italy
| | | | - Michelangelo Sartori
- Division of Angiology and Blood Coagulation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Adriana Visonà
- Angiology Unit, Azienda ULSS 2 Marca Trevigiana, Castelfranco Veneto, Italy
| | - Elisabetta Bigagli
- Department of Neuroscience, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
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Luo X, Zhang L, Hou C, Li P, Wu S, Wang Z, Yang E, Cui Y, Sun N, Yu Y, An Z, Jin J, Qin Z. Hospitalized patients with isolated distal deep vein thrombosis: anticoagulation therapy or not? Thromb J 2022; 20:52. [PMID: 36100922 PMCID: PMC9472408 DOI: 10.1186/s12959-022-00410-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background Isolated distal deep vein thrombosis (IDDVT), a disease frequently detected in hospitalized patients, can progress to proximal deep vein thrombosis (PDVT) and pulmonary embolism (PE). Here, we evaluated the effects of anticoagulation in hospitalized IDDVT patients. Methods We conducted a retrospective study in our hospital and enrolled hospitalized IDDVT patients diagnosed by compression ultrasonography (CUS) from January to December 2020. Participants were divided into anticoagulation (AC) and non-anticoagulation (non-AC) groups. After propensity score matching (PSM), multivariate Cox regression analyses were performed to assess whether anticoagulation was associated with PDVT/PE, and all-cause mortality. Results A total of 426 IDDVT inpatients with CUS follow-up were screened from 1502 distal DVT patients and finally enrolled. The median age was 67 years with 51.4% males and 15.5% cancer patients. The median follow-up was 11.6 months. There were 288 and 138 patients treated with or without anticoagulants, respectively. Patients in the non-AC group had less body mass index and more comorbidities. Patients in the AC group were treated with rivaroxaban or dabigatran (52.1%), low molecular weight heparin (42.7%), and warfarin (5.2%). The PSM generated 111 pairs of well-matched IDDVT patients with or without anticoagulation. The Kaplan–Meier analysis demonstrated that neither the incidence of PDVT/PE (5.4% vs. 2.7%, log-rank p = 0.313) nor all-cause mortality (27.9% vs. 18.9%, log-rank p = 0.098) was significant different between groups. Anticoagulation was not associated with PDVT/PE and all-cause mortality in the multivariable Cox regression analyses using the matched cohorts. The main risk factors for all-cause mortality were age, malignancy history, BMI, sepsis, heart failure, and white blood cell (WBC) count. Conclusions In hospitalized IDDVT patients, the thrombosis extension rate to PDVT/PE was low. Anticoagulation did not reduce the incidence of thrombosis extension of IDDVT and was not associated with all-cause mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00410-1.
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Affiliation(s)
- Xiaolin Luo
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China
| | - Liying Zhang
- Department of Cardiovascular Medicine, People's Hospital of Shapingba District, Chongqing, China
| | - Changchun Hou
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China
| | - Pengda Li
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China
| | - Shaofa Wu
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China
| | - Zebi Wang
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China
| | - Enpu Yang
- Department of Cardiology, People's Hospital of Dianjiang County, Chongqing, China
| | - Yun Cui
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China
| | - Ning Sun
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China
| | - Yang Yu
- Department of Cardiology, People's Hospital of Dianjiang County, Chongqing, China
| | - Zhixia An
- Department of Internal Medicine, Bashan Hospital, Chongqing, China
| | - Jun Jin
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China.
| | - Zhexue Qin
- Department of Cardiology, Xinqiao Hospital, Army Medical University, Shapingba District, No.183, Xinqiaozhengjie Street, Chongqing, China.
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Hu X, Li X, Xu H, Zheng W, Wang J, Wang W, Li S, Zhang N, Wang Y, Han K. Development of Risk Prediction Model for Muscular Calf Vein Thrombosis with Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Int J Gen Med 2022; 15:6549-6560. [PMID: 35974801 PMCID: PMC9375990 DOI: 10.2147/ijgm.s374777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/25/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose This study aims to establish a risk prediction model for muscular calf vein thrombosis (MCVT) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Methods The research sample consisted of 248 patients with AECOPD and all of them underwent vascular ultrasounds of both lower limbs in this retrospective study. Univariate analysis and multivariate logistic regression analysis were conducted on factors with significant group differences to screen for the independent risk factors of MCVT. A nomogram to predict the risk of MCVT was constructed and validated with bootstrap resampling. Results According to the exclusion criteria, 240 patients were included for analysis, divided into the MCVT group (n = 81) and the non-MCVT group (n = 159). Multivariate logistic regression analyses showed that hypertension, elevated MPV, reduced albumin (ALB), elevated D-dimer and bed rest ≥3 days were independent risk factors for MCVT in AECOPD. A nomogram model for predicting AECOPD with MCVT was established based on them. The area under the curve (AUC) of receiver operating characteristic (ROC) curve for the prediction model and the simplified Wells score was 0.784 (95% CI: 0.722–0.847) and 0.659 (95% CI: 0.583–0.735), respectively. The cut-off value and Youden index of prediction model were 0.248 and 0.454, respectively. At the same time, the sensitivity, specificity, positive predictive value, and negative predictive value of the prediction model were 85.9%, 59.5%, 84.6%, and 77.4%, respectively. The sensitivity and specificity of the simplified Wells score were 67.9% and 56.3%, respectively. Validation by the use of bootstrap resampling revealed optimal discrimination and calibration, and the decision analysis curve (DAC) suggested that this prediction model involved high clinical practicability. Conclusion We developed a nomogram that can predict the risk of MCVT for AECOPD patients. This model has the potential to assist clinicians in making treatment recommendations and formulating corresponding prevention measures.
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Affiliation(s)
- Xiaoman Hu
- Department of Respiratory and Critical Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Xincheng Li
- Department of Respiratory and Critical Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Huifen Xu
- Department of Respiratory and Critical Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Weili Zheng
- Department of Respiratory and Critical Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Jian Wang
- Department of Respiratory and Critical Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Wenyu Wang
- Department of Respiratory and Critical Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Senxu Li
- Department of Respiratory and Critical Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Ning Zhang
- Department of Respiratory and Critical Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Yunpeng Wang
- Department of Respiratory and Critical Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Kaiyu Han
- Department of Respiratory and Critical Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
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Zhao WG, Yan JY, Li XL, Shi CY, Wang ZY, Guo W, Zhang K, Zhang WL, Jia XC, Cui SB, Jiang LQ, Zhao JL, Liu ZW, Yang ZH, Liu L, Zhang YZ. Characteristics and Treatment Strategy of Isolated Calf Deep Venous Thrombosis after Fractures: A Review of Recent Literature. Orthop Surg 2022; 14:1263-1270. [PMID: 35478486 PMCID: PMC9251287 DOI: 10.1111/os.13292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 03/10/2022] [Accepted: 03/26/2022] [Indexed: 12/03/2022] Open
Abstract
Isolated calf deep venous thrombosis (ICDVT) includes thrombosis located at the far end of the popliteal vein, such as the anterior tibial vein, posterior tibial vein, fibular vein, and intramuscular vein of the soleus and gastrocnemius. This type of thrombosis has the highest incidence, accounting for approximately half of all deep vein thrombosis (DVT) cases; however, there is no consistent recommendation for ICDVT treatment across countries, and there is also no optimal management strategy. In recent years, increasing evidence has shown that ICDVT can develop into proximal DVT, even causing pulmonary embolism (PE). Therefore, some experts suggest anticoagulant therapy for this type of DVT, while others hold an opposing attitude. Therefore, the treatment strategy for this type of DVT has become a hot and difficult research topic. The purpose of this review is to summarize the characteristics of ICDVT and the effects of different treatment strategies by analyzing recent and important classical works in the literature in an attempt to provide recommendations for the treatment of this most common type of DVT in orthopaedic clinics.
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Affiliation(s)
- Wei-Guang Zhao
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Ji-Ying Yan
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Xiao-Lei Li
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Cai-Ying Shi
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Zhi-Yun Wang
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Wei Guo
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Kai Zhang
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Wei-Li Zhang
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Xiao-Chuan Jia
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Shu-Bei Cui
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Li-Qiang Jiang
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Jian-Long Zhao
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Zhen-Wu Liu
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Zhao-Hui Yang
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Li Liu
- Department of Orthopedic Surgery, HanDan Central Hospital, HanDan, Hebei, China
| | - Ying-Ze Zhang
- Key Laboratory of Biomechanics of Hebei Province, Department of Trauma Emergency Center, the Third Hospital of Hebei Medical University, Orthopaedics Research Institution of Hebei Province, Shijiazhuang, Hebei, China.,NHC Key Laboratory of Intelligent Orthopeadic Equipment, (The Third Hospital of Hebei Medical University), Shijiazhuang, Hebei, China.,Chinese Academy of Engineering, Beijing, China
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10
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Zhou M, Zhang W, Zhang Y, Xie T, Mao J, Shi Z. Therapeutic or prophylactic anticoagulation in acute isolated distal deep vein thrombosis: protocol for a prospective, multicentre, single-blind, randomised controlled trial (TOP-IDDVT). BMJ Open 2022; 12:e056826. [PMID: 35228291 PMCID: PMC8886414 DOI: 10.1136/bmjopen-2021-056826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION The efficacy and safety of anticoagulant treatment is not established for patients with acute symptomatic isolated distal deep vein thrombosis (IDDVT). In real-world clinical practice, both therapeutic and prophylactic anticoagulation are used for acute IDDVT. However, therapeutic anticoagulation is associated with higher risk of bleeding than prophylactic anticoagulation. Thus, this study aims to assess the efficacy and safety in patients with first acute symptomatic IDDVT treated with therapeutic or prophylactic anticoagulation using rivaroxaban. METHODS AND ANALYSIS This study is a prospective, multicentre, single-blind, randomised controlled trial. Outpatients with a first, acute, symptomatic, objectively confirmed IDDVT in four centres from 1 August 2021 are recruited. Eligible patients are randomised in a 1:1 ratio to receive prophylactic anticoagulation (rivaroxaban 10 mg once a day for 3 months) or therapeutic anticoagulation (rivaroxaban 20 mg once a day for 3 months). All patients are followed for 6 months. The primary efficacy outcome is radiographically confirmed recurrent venous thromboembolism. The primary safety outcome is the incidence of major or clinically relevant non-major bleeding events. ETHICS AND DISSEMINATION This study has been approved by the Ethics Committee of Zhongshan Hospital Fudan University (B2021-175R). Study results will be disseminated through peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04967573.
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Affiliation(s)
- Min Zhou
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Wan Zhang
- Department of Vascular Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Yucheng Zhang
- Department of Vascular Surgery, Wusong Branch, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tianchen Xie
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Jieqi Mao
- Department of Vascular Surgery, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Zhenyu Shi
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, Shanghai, China
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11
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Palareti G, Bignamini AA, Urbanek T, Cini M, Li YJ, Madaric J, Bouslama K, Sokurenko GY, Andreozzi GM, Matuška J, Mansilha A, Barinov V. Influence of clinical presentation, site, and extent of venous thrombosis on decision about duration of anticoagulation: Data from the international, prospective, observational white study. Thromb Res 2022; 211:140-146. [DOI: 10.1016/j.thromres.2022.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/17/2022] [Accepted: 01/26/2022] [Indexed: 10/19/2022]
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12
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Chang J. Pathogenesis of Two Faces of DVT: New Identity of Venous Thromboembolism as Combined Micro-Macrothrombosis via Unifying Mechanism Based on “Two-Path Unifying Theory” of Hemostasis and “Two-Activation Theory of the Endothelium”. Life (Basel) 2022; 12:220. [PMID: 35207507 PMCID: PMC8874373 DOI: 10.3390/life12020220] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary DVT is an intravascular blood clotting disorder that can be a life-threatening disease, particularly if it occurs in critically ill patients. Typically, distal DVT develops following a vascular injury associated with incidental trauma commonly involving lower extremities, which is transient and benign condition localized in the lower legs as solitary lesion. However, proximal/central DVT (i.e., venous thromboembolism) typically occurs in association with critical illnesses such as sepsis, diabetes, hypertension, cancer, autoimmune disease and others in the hospitalized patient, especially in the ICU. Recognition of different pathogenesis between distal DVT and proximal/central DVT is critically important because the prognosis is poorer in VTE. Its therapeutic approach should be different from distal DVT. The aim of this review is to identify the pathogenesis of two different types of DVT based on in vivo hemostatic mechanisms, which can explain their distinct phenotypes by clinical characteristics, laboratory data and imaging findings. An appropriate preventive measure can be put into the practice to avoid the onset of VTE. Additionally, should VTE be developed, proper and rational therapeutic regimen based on its pathogenesis can be designed for clinical trials to improve the outcome. Abstract Venous thrombosis includes deep venous thrombosis (DVT), venous thromboembolism (VTE), venous microthrombosis and others. Still, the pathogenesis of each venous thrombosis is not clearly established. Currently, isolated distal DVT and multiple proximal/central DVT are considered to be the same macrothrombotic disease affecting the venous system but with varying degree of clinical expression related to its localization and severity. The genesis of two phenotypes of DVT differing in clinical features and prognostic outcome can be identified by their unique hemostatic mechanisms. Two recently proposed hemostatic theories in vivo have clearly defined the character between “microthrombi” and “macrothrombus” in the vascular system. Phenotypic expression of thrombosis depends upon two major variables: (1) depth of vascular wall damage and (2) extent of the injury affecting the vascular tree system. Vascular wall injury limited to endothelial cells (ECs) in sepsis produces “disseminated” microthrombi, but intravascular injury due to trauma extending from ECs to subendothelial tissue (SET) produces “local” macrothrombus. Pathogen-induced sepsis activates the complement system leading to generalized endotheliopathy, which releases ultra large von Willebrand factor (ULVWF) multimers from ECs and promotes ULVWF path of hemostasis. In the venous system, the activated ULVWF path initiates microthrombogenesis to form platelet-ULVWF complexes, which become “microthrombi strings” that produce venous endotheliopathy-associated vascular microthrombotic disease (vEA-VMTD) and immune thrombocytopenic purpura (ITP)-like syndrome. In the arterial system, endotheliopathy produces arterial EA-VMTD (aEA-VMTD) with “life-threatening” thrombotic thrombocytopenic purpura (TTP)-like syndrome. Typically, vEA-VMTD is “silent” unless complicated by additional local venous vascular injury. A local venous vessel trauma without sepsis produces localized macrothrombosis due to activated ULVWF and tissue factor (TF) paths from damaged ECs and SET, which causes distal DVT with good prognosis. However, if a septic patient with “silent” vEA-VMTD is complicated by additional vascular injury from in-hospital vascular accesses, “venous combined micro-macrothrombosis” may develop as VTE via the unifying mechanism of the “two-path unifying theory” of hemostasis. This paradigm shifting pathogenetic difference between distal DVT and proximal/central DVT calls for a reassessment of current therapeutic approaches.
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13
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Mahajan A, Brunson A, Eldredge J, White RH, Keegan T, Wun T. Incidence and Outcomes Associated with 6841 Isolated Distal Deep Vein Thromboses in Patients with 13 Common Cancers. Thromb Haemost 2022; 122:1407-1414. [PMID: 35038763 DOI: 10.1055/a-1742-0177] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION The epidemiology of isolated distal deep venous thrombosis (iDDVT) among cancer patients is not well described, particularly the incidence of recurrent venous thromboembolism (rVTE) and effect on mortality by cancer type. METHODS The cumulative incidence (CI) of iDDVT was determined for patients with 13 common cancers between 2005-2017 using the California Cancer Registry linked to the California Patient Discharge and Emergency Department Utilization datasets. The CI of rVTE was calculated and association of incident CAT location with rVTE was determined using Cox proportional hazards regression models. The association of incident cancer-associated venous thrombosis (CAT) location with overall and cancer-specific mortality was determined using Cox models, stratified by cancer site, and adjusted for individual characteristics. RESULTS Among 942,109 cancer patients, CAT occurred in 62,003 (6.6%): of these, 6,841 (11.0%) were iDDVT. Compared to more proximal sites of CAT, iDDVT was associated with similar risk for rVTE. IDDVT was associated with increased mortality across all cancer types when compared to patients without CAT (HR 1.56-4.60). The effect of iDDVT on mortality was similar to that of proximal DVT (pDVT) for most cancers except lung, colorectal, bladder, uterine, brain, and myeloma, where iDDVT was associated with a lesser association with mortality. CONCLUSION iDDVT represented 11% of CAT. The risk of rVTE after iDDVT was similar to other sites of CAT and rVTE occurred in more proximal locations after an incident iDDVT. IDDVT was associated with increased mortality and this effect was similar to that of PE or pDVT for most cancer types.
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Affiliation(s)
- Anjlee Mahajan
- Hematology/Oncology, University of California Davis Health System, Sacramento, United States
| | - Ann Brunson
- Hematology/Oncology, University of California Davis Health System, Sacramento, United States
| | - Joanna Eldredge
- Hematology/Oncology, University of California Davis Health System, Sacramento, United States
| | - Richard H White
- Internal Medicine, University of California Davis Health System, Sacramento, United States
| | - Theresa Keegan
- Hematology/Oncology, University of California Davis Health System, Sacramento, United States
| | - Ted Wun
- Hematology/Oncology, University of California Davis Health System, Sacramento, United States
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14
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Palareti G, Bignamini AA, Cini M, Li YJ, Urbanek T, Madaric J, Bouslama K, Sokurenko GY, Andreozzi GM, Matuška J, Mansilha A, Barinov V. Anticoagulation Duration After First Venous Thromboembolism: Real-Life Data From the International, Observational WHITE Study. Clin Appl Thromb Hemost 2021; 27:10760296211049402. [PMID: 34841907 PMCID: PMC8674483 DOI: 10.1177/10760296211049402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background International guidelines recommend at least three months anticoagulation in
all patients after acute venous thromboembolism (VTE) and suggest those with
unprovoked events be considered for indefinite anticoagulation if the risk
of recurrence is high and the risk of bleeding during treatment non-high.
Other authors have recently argued against using a dichotomy
unprovoked/provoked events to decide on anticoagulation duration and suggest
instead using overall risk factors present in each patient as the basis for
deciding. Aim This sub-analysis of the WHITE study aimed at assessing the reasons for the
treatment decisions taken by doctors in different countries. Results 1240 patients were recruited in 7 countries (China, Czechia, Poland,
Portugal, Russia, Slovakia, and Tunisia). Anticoagulation was extended in
51.7% and 49.3% of patients with unprovoked or provoked events (n.s.);
stopped in 15.4% versus 28.9% (P < .0001), and changed
to antithrombotic drugs (sulodexide or aspirin) in 32.9% versus 21.8%
(P < .0001). In the 430 subjects with isolated
distal deep vein thrombosis (IDDVT) anticoagulation was stopped in 34.4%,
continued in 37.0% (mainly those with post-thrombotic syndrome [PTS]) and
switched to antithrombotics in the balance. High risk of recurrence was the
most prevalent reason (>83% of cases) given to continue anticoagulation,
regardless of nature and site of the index events, followed by risk of
bleeding and presence of PTS signs. Conclusion On average, attending physicians estimated the risk of recurrence in real
life conditions, and the consequent therapeutic decision, using all the
information available, not limiting to the location or nature of the index
event.
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Affiliation(s)
| | - Angelo A Bignamini
- School of Specialization in Hospital Pharmacy, 9304University of Milan, Milan, Italy
| | - Michela Cini
- Arianna Anticoagulazione Foundation, Bologna, Italy
| | - Young-Jun Li
- Peking Union Medical College, 12501Chinese Academy of Medical Sciences, Beijing, China
| | | | - Juraj Madaric
- Clinic of Angiology, Comenius University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | - Kamel Bouslama
- Faculty of Medicine of Tunis, 59074University of Tunis El Manar, Tunis, Tunisia
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15
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Vlazny DT, Pasha AK, Kuczmik W, Wysokinski WE, Bartlett M, Houghton D, Casanegra AI, Daniels P, Froehling DA, White LJ, Hodge DO, McBane RD. Outcome of anticoagulation in isolated distal deep vein thrombosis compared to proximal deep venous thrombosis. J Thromb Haemost 2021; 19:2206-2215. [PMID: 34060224 DOI: 10.1111/jth.15416] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Isolated, distal deep vein thrombosis (IDDVT) is thought to have low rates of propagation, embolization, and recurrence compared with proximal DVT (PDVT), but the data are limited. OBJECTIVES The objective of this study was to assess outcomes among patients with IDDVT compared with PDVT. PATIENTS/METHODS Consecutive patients with ultrasound-confirmed acute DVT (March 1, 2013-August 1, 2020) were identified by reviewing the Mayo Clinic Gonda Vascular Center and VTE Registry databases. Patients were divided into two groups depending on the DVT location (isolated, distal vs. proximal DVT). Outcomes including venous thromboembolism (VTE) recurrence, major bleeding, and death were compared by thrombus location and anticoagulant therapy, warfarin vs. direct oral anticoagulant (DOAC). RESULTS Isolated, distal deep vein thrombosis (n = 746) was more often associated with recent surgery, major trauma, or confinement (p < .001), whereas patients with PDVT (n = 1176) were more frequently unprovoked, had a prior history of VTE, or active cancer (p < .001). There was no overall difference in VTE recurrence or major bleeding between groups during follow-up. Patients with IDDVT had a higher death rate at 3 months (p = .001) and when propensity scored for cancer (p = .003). Independent predictors of mortality included warfarin (vs. DOAC) therapy, increasing age, and active cancer. DOAC therapy resulted in lower VTE recurrence, major bleeding, and death rates in both groups. CONCLUSION Outcomes of IDDVT including VTE recurrence and bleeding rates were similar to PDVT despite higher early mortality rates. Outcomes for both groups were positively influenced by the use of DOACs.
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Affiliation(s)
- Danielle T Vlazny
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | - Ahmed K Pasha
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | | | - Waldemar E Wysokinski
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | | | - Damon Houghton
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | - Ana I Casanegra
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | - Paul Daniels
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - David A Froehling
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | - Launia J White
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Robert D McBane
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
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16
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Makedonov I, Galanaud JP, Kahn SR. Significance and management of isolated distal deep vein thrombosis. Curr Opin Hematol 2021; 28:331-338. [PMID: 34267078 DOI: 10.1097/moh.0000000000000670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Management of isolated distal deep vein thrombosis (IDDVT) remains controversial. We summarize recent studies regarding the natural history of IDDVT as well as pertinent therapeutic trials. We also provide our management approach. RECENT FINDINGS IDDVT is more commonly associated with transient risk factors and less often associated with permanent, unmodifiable risk factors than proximal DVT. IDDVT has a significantly lower risk of proximal extension and recurrence than proximal DVT. Cancer-associated IDDVT has a similar natural history to cancer-associated proximal DVT, with substantially less favourable outcomes than noncancer-associated IDDVT. Anticoagulant treatment reduces the risk of proximal extension and recurrence in IDDVT at the cost of increased bleeding risk. Intermediate dosing of anticoagulation may be effective for treating noncancer-associated IDDVT in patients without prior DVT. SUMMARY IDDVT with a transient risk factor can be treated for 6 weeks in patients without a prior DVT. Unprovoked IDDVT in patients without malignancy can be treated for 3 months. Outpatients without malignancy or a prior DVT can be left untreated and undergo surveillance compression ultrasound in one week to detect proximal extension, but few patients opt for this in practice. Cancer-associated IDDVT should be treated analogously to cancer-associated proximal DVT.
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Affiliation(s)
- Ilia Makedonov
- Department of Medicine, Division of General Internal Medicine, Sunnybrook Health Sciences Center
| | - Jean-Philippe Galanaud
- Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario
| | - Susan R Kahn
- Center for Clinical Epidemiology, Jewish General Hospital/Lady Davis Institute; Division of Internal Medicine, Department of Medicine, McGill University, Montreal, Québec, Canada
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17
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Palareti G, Legnani C, Antonucci E, Testa S, Mastroiacovo D, Cosmi B, Poli D, Bucherini E, Dentali F, Fontanella A, Mumoli N, Imberti D, Falanga A, Ageno W, Pomero F. Management and Outcomes of Isolated Distal Deep Vein Thromboses: A Questionable Trend toward Long-Lasting Anticoagulation Treatment. Results from the START-Register. TH Open 2021; 5:e239-50. [PMID: 34263110 DOI: 10.1055/s-0041-1730038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/12/2021] [Indexed: 12/18/2022] Open
Abstract
Background
Isolated distal deep vein thromboses (IDDVT) are frequently diagnosed; however, their natural history and real risk of complications are still uncertain. Though treatment is still not well standardized, international guidelines recommend no more than 3 months of anticoagulation therapy. We investigated how Italian clinicians treat IDDVT patients in their real life in our country.
Methods
Baseline characteristics and clinical history of the patients enrolled in the prospective, observational, multicenter START-Register for a first IDDVT or proximal DVT (PDVT) were analyzed.
Results
Overall, 412 IDDVT patients were significantly younger, with better renal function, and more frequent major transient risk factors, when compared with 1,173 PDVT patients. The anticoagulation duration was >180 days in 52.7% of IDDVT patients (70.7% in PDVT). During treatment, bleeding occurred in 5.6 and 2.8% patient-years in IDDVT and PDVT, respectively (
p
= 0082). Bleeding was more frequent in IDDVT than PDVT patients treated with warfarin (6.8 vs. 3.2 patient-years,
p
= 0.0228, respectively). Thrombotic complications occurred in 1.1 and 2.4% patient-years in IDDVT and PDVT patients, respectively. Analyzing together the two groups, 66.1% of bleeds and 86.1% thrombotic complications occurred after 90 days anticoagulation treatment.
Conclusion
The large majority of IDDVT patients received anticoagulation for more than 3 months. Most bleeding and thrombotic complications occurred after the first 90 days of anticoagulation therapy. These results indicate that an extended anticoagulation beyond 90 days in IDDVT patients is associated with increased risk of complications. Whether an extended treatment may lower recurrences after anticoagulation withdrawal should be assessed by specifically designed studies.
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18
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Schellong S, Ageno W, Casella IB, Chee KH, Schulman S, Singer DE, Desch M, Tang W, Voccia I, Zint K, Goldhaber SZ. Profile of Patients with Isolated Distal Deep Vein Thrombosis versus Proximal Deep Vein Thrombosis or Pulmonary Embolism: RE-COVERY DVT/PE Study. Semin Thromb Hemost 2021; 48:446-458. [PMID: 33971682 DOI: 10.1055/s-0041-1729169] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Isolated distal deep vein thrombosis (IDDVT) is presumed to be more benign than proximal DVT (PDVT) or pulmonary embolism (PE), suggesting a need for different management approaches. This subgroup analysis of the RE-COVERY DVT/PE global, observational study investigated patient characteristics, hospitalization details, and anticoagulant therapy in patients with IDDVT in real-world settings in 34 countries enrolled from January 2016 to May 2017. Data were analyzed descriptively according to the type and location of the index venous thromboembolism (VTE): IDDVT, PDVT ± distal DVT (DDVT), and PE ± DVT. Of the 6,095 eligible patients, 323 with DVT located outside the lower limb and no PE were excluded. Of the remaining 5,772 patients, 17.6% had IDDVT, 39.9% had PDVT ± DDVT, and 42.5% had PE ± DVT. IDDVT patients were younger and had fewer risk factors for VTE than the other groups. Other comorbidities were less frequent in the IDDVT group, except for varicose veins, superficial thrombophlebitis, and venous insufficiency. IDDVT patients were less likely to be diagnosed in an emergency department (22.3 vs. 29.7% for PDVT ± DDVT and 45.4% for PE ± DVT) or hospitalized for VTE (29.2 vs. 48.5% for PDVT ± DDVT and 75.0% for PE ± DVT). At hospital discharge or 14 days after diagnosis (whichever was later), non-vitamin K antagonist oral anticoagulants were the most commonly used anticoagulants (55.6% for IDDVT, 54.7% for PDVT ± DDVT, and 52.8% for PE ± DVT). Although differences in patient characteristics, risk factors, and clinical management were identified, anticoagulant treatment of IDDVT was almost equal to that of PDVT or PE. Prospective studies should investigate whether, in a global perspective, this is an appropriate use of anticoagulants. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT02596230.
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Affiliation(s)
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Ivan B Casella
- Department of Surgery, Clinics Hospital, University of São Paulo, São Paulo, Brazil
| | - Kok Han Chee
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Ontario, Canada.,Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Daniel E Singer
- Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marc Desch
- CardioMetabolism Respiratory Medicine, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Wenbo Tang
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut
| | - Isabelle Voccia
- Clinical Operations, Boehringer Ingelheim Canada, Burlington, Ontario, Canada
| | - Kristina Zint
- Department of Epidemiology, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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19
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Sartori M, Favaretto E, Cosmi B. Relevance of immobility as a risk factor for symptomatic proximal and isolated distal deep vein thrombosis in acutely ill medical inpatients. Vasc Med 2021; 26:542-548. [PMID: 33813966 DOI: 10.1177/1358863x21996825] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Immobility is a well-recognized risk factor for deep vein thrombosis (DVT) in surgical patients, whereas the level of DVT risk conferred by immobility is less defined in patients on medical wards. The aim of this study was to establish whether immobility and its duration are associated with the risk of DVT in acutely ill medical inpatients. We conducted a cohort study in acutely ill medical inpatients. Patients underwent whole leg ultrasound for suspected lower extremity DVT and were divided into two groups according to presence or absence of immobility, defined as total bed rest or sedentary without bathroom privileges. The endpoint was the detection of proximal DVT or isolated distal DVT (IDDVT). Among the 252 acutely ill medical inpatients with immobility (age 82.6 ± 10.3 years, female 63.9%), ultrasound showed 36 (14.3%) proximal DVTs and 39 (15.5%) IDDVTs, while there were 11 (4.4%) proximal DVTs and 26 (10.5%) IDDVTs among the 248 inpatients without immobility (age 73.6 ± 14.2 years, female 54.8%). The risk of proximal DVT was higher in immobile than in mobile patients (OR 3.59, 95% CI: 1.78-7.23, p = 0.0001), whereas the risk of IDDVT was similar between the two groups (OR 1.56, 95% CI: 0.92-2.66, p = 0.111). During the first 3 days of hospitalization, the frequency of all DVTs was similar in patients with and without immobility, but it was 0.26 ± 0.03 vs 0.18 ± 0.03, respectively, after 4 days. In conclusion, immobility for more than 3 days is a risk factor for proximal DVT in acutely ill medical inpatients.
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Affiliation(s)
- Michelangelo Sartori
- Division of Angiology and Blood Coagulation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Elisabetta Favaretto
- Division of Angiology and Blood Coagulation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Benilde Cosmi
- Division of Angiology and Blood Coagulation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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20
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Cheng HR, Huang GQ, Wu ZQ, Wu YM, Lin GQ, Song JY, Liu YT, Luan XQ, Yuan ZZ, Zhu WZ, He JC, Wang Z. Individualized predictions of early isolated distal deep vein thrombosis in patients with acute ischemic stroke: a retrospective study. BMC Geriatr 2021; 21:140. [PMID: 33632136 PMCID: PMC7908755 DOI: 10.1186/s12877-021-02088-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/09/2021] [Indexed: 02/06/2023] Open
Abstract
Background Although isolated distal deep vein thrombosis (IDDVT) is a clinical complication for acute ischemic stroke (AIS) patients, very few clinicians value it and few methods can predict early IDDVT. This study aimed to establish and validate an individualized predictive nomogram for the risk of early IDDVT in AIS patients. Methods This study enrolled 647 consecutive AIS patients who were randomly divided into a training cohort (n = 431) and a validation cohort (n = 216). Based on logistic analyses in training cohort, a nomogram was constructed to predict early IDDVT. The nomogram was then validated using area under the receiver operating characteristic curve (AUROC) and calibration plots. Results The multivariate logistic regression analysis revealed that age, gender, lower limb paralysis, current pneumonia, atrial fibrillation and malignant tumor were independent risk factors of early IDDVT; these variables were integrated to construct the nomogram. Calibration plots revealed acceptable agreement between the predicted and actual IDDVT probabilities in both the training and validation cohorts. The nomogram had AUROC values of 0.767 (95% CI: 0.742–0.806) and 0.820 (95% CI: 0.762–0.869) in the training and validation cohorts, respectively. Additionally, in the validation cohort, the AUROC of the nomogram was higher than those of the other scores for predicting IDDVT. Conclusions The present nomogram provides clinicians with a novel and easy-to-use tool for the prediction of the individualized risk of IDDVT in the early stages of AIS, which would be helpful to initiate imaging examination and interventions timely.
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Affiliation(s)
- Hao-Ran Cheng
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Gui-Qian Huang
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Zi-Qian Wu
- Department of Neurology, Wenzhou Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University, Wenzhou, 325000, Zhejiang, China
| | - Yue-Min Wu
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Gang-Qiang Lin
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Jia-Ying Song
- School of Mental Health, Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Yun-Tao Liu
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Xiao-Qian Luan
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Zheng-Zhong Yuan
- Department of Traditional Chinese Medicine, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Wen-Zong Zhu
- Department of Neurology, Wenzhou Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University, Wenzhou, 325000, Zhejiang, China.
| | - Jin-Cai He
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China.
| | - Zhen Wang
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China.
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21
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Pasha AK, Kuczmik W, Wysokinski WE, Casanegra AI, Houghton D, Vlazny DT, Mertzig A, Hirao-Try Y, White L, Hodge D, McBane Ii R. Calf vein thrombosis outcomes comparing patients with and without cancer. J Thromb Thrombolysis 2021; 51:1059-1066. [PMID: 33538988 DOI: 10.1007/s11239-021-02390-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2021] [Indexed: 11/26/2022]
Abstract
Distal or calf deep vein thrombosis (DVT) are said to have low rates of propagation, embolization, and recurrence. The objective of this study was to determine outcomes among cancer patients with calf DVT compared to those without cancer. Consecutive patients with ultrasound confirmed acute calf DVT (3/1/2013-8/10/2019) were assessed for venous thromboembolism (VTE) recurrence and bleeding outcomes compared by cancer status. There were 830 patients with isolated calf DVT; 243 with cancer and 587 without cancer. Cancer patients were older (65.9 ± 11.4 vs. 62.0 ± 15.9 years; p = 0.006), with less frequent recent hospitalization (31.7% vs. 48.0%; p < 0.001), surgery (30.0% vs. 38.0%; p = 0.03), or trauma (3.7% vs. 19.9%; p < 0.001). The four most common cancers included hematologic malignancies (20.6%), lung (11.5%), gastrointestinal (10.3%), and ovarian/GYN (9.1%). Nearly half of patients had metastatic disease (43.8%) and 57% were receiving chemotherapy. VTE recurrence rates were similar for patients with (7.1%) and without cancer (4.0%; p = 0.105). Major bleeding (6.3% vs. 2.3%; p = 0.007) were greater for cancer patients while clinical relevant non major bleeding rates did not differ (7.1% vs. 4.6%; p = 0.159). In this retrospective analysis, cancer patients with calf DVT have similar rates of VTE recurrence but higher major bleeding outcomes compared to patients without cancer.
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Affiliation(s)
- Ahmed K Pasha
- Gonda Vascular Center, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, 55905, USA
| | - Wiktoria Kuczmik
- Gonda Vascular Center, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Waldemar E Wysokinski
- Gonda Vascular Center, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, 55905, USA
| | - Ana I Casanegra
- Gonda Vascular Center, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, 55905, USA
| | - Damon Houghton
- Gonda Vascular Center, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, 55905, USA
| | - Danielle T Vlazny
- Gonda Vascular Center, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, 55905, USA
| | - Abigail Mertzig
- Gonda Vascular Center, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, 55905, USA
| | - Yumiko Hirao-Try
- Gonda Vascular Center, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, 55905, USA
| | - Launia White
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - David Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Robert McBane Ii
- Gonda Vascular Center, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Cardiovascular Department, Mayo Clinic, Rochester, MN, 55905, USA.
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22
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Engeseth M, Enden T, Sandset PM, Wik HS. Predictors of long-term post-thrombotic syndrome following high proximal deep vein thrombosis: a cross-sectional study. Thromb J 2021; 19:3. [PMID: 33419441 PMCID: PMC7796540 DOI: 10.1186/s12959-020-00253-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 12/16/2020] [Indexed: 11/10/2022] Open
Abstract
Background Post-thrombotic syndrome (PTS) is a frequent chronic complication of proximal deep vein thrombosis (DVT) of the lower limb, but predictors of PTS are not well established. We aimed to examine predictors of PTS in patients with long-term PTS following proximal DVT. Methods During 2006–09, 209 patients with a first time acute upper femoral or iliofemoral DVT were randomized to receive either additional catheter-directed thrombolysis or conventional therapy alone. In 2017, the 170 still-living participants were invited to participate in a cross-sectional follow-up study. In the absence of a gold standard diagnostic test, PTS was defined in line with clinical practice by four mandatory, predefined clinical criteria: 1. An objectively verified DVT; 2. Chronic complaints (> 1 month) in the DVT leg; 3. Complaints appeared after the DVT; and 4. An alternative diagnosis was unlikely. Possible predictors of PTS were identified with multivariate logistic regression. Results Eighty-eight patients (52%) were included 8–10 years following the index DVT, and 44 patients (50%) were diagnosed with PTS by the predefined clinical criteria. Younger age and higher baseline Villalta score were found to be independent predictors of PTS, i.e., OR 0.96 (95% CI, 0.93–0.99), and 1.23 (95% CI, 1.02–1.49), respectively. Lack of iliofemoral patency at six months follow-up was significant in the bivariate analysis, but did not prove to be significant after the multivariate adjustments. Conclusions In long-term follow up after high proximal DVT, younger age and higher Villalta score at DVT diagnosis were independent predictors of PTS.
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Affiliation(s)
- Marit Engeseth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Haematology, Oslo University Hospital, P.O.Box 4950 Nydalen, N-0424, Oslo, Norway
| | - Tone Enden
- Division of Radiology and Nuclear medicine, Oslo University Hospital, Oslo, Norway
| | - Per Morten Sandset
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Haematology, Oslo University Hospital, P.O.Box 4950 Nydalen, N-0424, Oslo, Norway
| | - Hilde Skuterud Wik
- Department of Haematology, Oslo University Hospital, P.O.Box 4950 Nydalen, N-0424, Oslo, Norway.
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23
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Elmi G, Aluigi L, Allegri D, Rinaldi ER, Camaggi V, Di Giulio R, Martignani A, Bacchi Reggiani ML, Domanico A, Antignani PL. Calf deep vein thrombosis: frequency, therapeutic management, early outcomes and all-causes mortality in a cohort of hospitalized patients. INT ANGIOL 2020; 39:467-476. [PMID: 33215909 DOI: 10.23736/s0392-9590.20.04528-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Isolated distal deep vein thromboses (IDDVT) are frequent; however, their optimal management is still controversial. METHODS We performed a retrospective study on inpatients undergoing ultrasound for suspected deep vein thrombosis (DVT) or with a particular risk profile, during 2016. This study aimed to assess the frequency of proximal deep vein thromboses (PDVT) and IDDVT; to evaluate therapeutic management and identify variables associated with early outcomes and mortality among IDDVT patients; to compare all-causes mortality between subjects with PDVT and IDDVT. RESULTS Among 21594 patients hospitalized in the study period 251 IDDVT and 149 PDVT were diagnosed; the frequency was 1.2% and 0.7% respectively. 19% of IDDVT patients died compared to 25.5% of PDVT subjects (OR=0.72; 95% CI=0.44-1.17; P=0.19). In IDDVT patients, age ≥80, cancer and intracranial bleeding increased the risk of death (OR=2; 95% CI=1.07-3.75, P=0.001; OR=8.47; 95% CI=3.28-21.88, P=0.0000003; OR=2.33; 95% CI=1.18-4.58, P=0.0003). A significant association between intracranial hemorrhage and both proximal extension by using the Fisher's exact test (P=0.031; OR=16.11; 95% CI=0.80-321.2), and composite of propagation to popliteal or to other calf veins (OR=8.28, 95% CI=2.07-33 P=0.001) was observed. Standard anticoagulation significantly reduced the composite of propagation to popliteal or to other calf veins (OR=0.07; 95% CI=0.009-0.61, P=0.007), and all-causes mortality (OR=0.37; 95% CI=0.17-0.8; P=0.02), without a significant increase of bleeding. CONCLUSIONS Among inpatients, IDDVT exceeded 60% of DVT. Mortality was not significantly different between IDDVT and PDVT subjects. Intracranial bleeding significantly increased the risk of propagation and death. Although standard anticoagulation decreased both these complications, further targeted studies are needed.
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Affiliation(s)
- Giovanna Elmi
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy -
| | | | - Davide Allegri
- Department of Clinical Governance and Quality, Bologna Local Healthcare Authority, Bologna, Italy
| | - Elisa R Rinaldi
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Valeria Camaggi
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Rosella Di Giulio
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Alberto Martignani
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Maria L Bacchi Reggiani
- Department of Specialistic, Diagnostic and Experimental Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Andrea Domanico
- Ultrasound Program, Department of Medicine, Maggiore Hospital, AUSL Bologna, Bologna, Italy
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24
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Galanaud JP, Trujillo-Santos J, Bikdeli B, Di Micco P, Bortoluzzi C, Bertoletti L, Pedrajas JM, Ballaz A, Alfonso J, Monreal M; RIETE Investigators. Management of isolated distal deep-vein thrombosis with direct oral anticoagulants in the RIETE registry. J Thromb Thrombolysis 2020. [PMID: 33247808 DOI: 10.1007/s11239-020-02347-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 12/14/2022]
Abstract
Isolated distal deep-vein thrombosis (DVT, infra-popliteal DVT without pulmonary embolism) is a common presentation of venous thromboembolism (VTE), but was an exclusion criterion from the pivotal trials that validated the use of direct oral anticoagulants (DOACs) for VTE management. Using data from the international RIETE registry, we analyzed and compared trends in DOACs prescription between January 2011 and June 2019 in patients with distal vs. proximal DVT. We also assessed DOACs' prescriptions and compared the outcomes (VTE recurrence, bleeding and death) of distal DVT patients treated with DOACs vs. those on vitamin K antagonists (VKAs). 2308 patients with distal DVT and 11,364 patients with proximal DVT were included in the current analysis. DOACs were more frequently prescribed in patients with distal than proximal DVT (25% vs. 16%, p < 0.001). DOACs use increased sharply during the observation period (P < 0.001 for trend). In 2018, 56% of patients with distal DVT received DOACs. Distal DVT patients treated with rivaroxaban or edoxaban received the dose recommended for VTE management in most (> 85%) cases. Patients treated with apixaban were older, more likely to have underlying conditions than patients treated with rivaroxaban and, in most cases (> 75%), did not receive the recommended 1-week loading dose for acute VTE management. Outcomes between distal DVT patients treated with VKAs or DOACs appeared to be similar. In patients with distal DVT, DOACs have become the most common anticoagulant regimen. Specific trials are needed to determine the optimal DOACs dose regimen for treatment of distal DVT.
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25
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Galanaud J, Sevestre M, Pernod G, Genty C, Richaud C, Rolland C, Weber L, Kahn SR, Quéré I, Bosson J. Epidemiology and 3-year outcomes of combined oral contraceptive-associated distal deep vein thrombosis. Res Pract Thromb Haemost 2020; 4:1216-1223. [PMID: 33134787 PMCID: PMC7590310 DOI: 10.1002/rth2.12409] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Distal deep vein thrombosis (infrapopliteal DVT without proximal DVT or pulmonary embolism [PE]) generally shares the same triggering risks factors as proximal DVT. In women of childbearing age, a frequent triggering risk factor is the use of combined oral contraceptive (COC) pills. However, data on the epidemiology and long-term outcomes of COC-associated distal DVT are lacking. OBJECTIVES To assess the epidemiology and long-term outcomes of COC-associated distal DVT. METHODS Using data from the OPTIMEV (Optimisation de l'Interrogatoire dans l'évaluation du risque thrombo-Embolique Veineux [Optimization of Interrogation in the Assessment of Thromboembolic Venous Risk]) multicenter cohort study of patients with objectively confirmed venous thromboembolism (VTE) enrolled between 2004 and 2006, we assessed in nonpregnant or postpartum women aged ≤ 50 years without cancer or history of VTE (i) proportion of COC-associated distal DVTs among women with distal DVTs and among women with COC-associated VTEs (distal DVT, proximal DVT, or PE) and (ii) 3-year incidence of death, bleeding, and VTE recurrence. RESULTS COC-associated distal DVTs (n = 54) represented 43.9% of all distal DVTs and 51.9% of COC-associated VTEs. All but one woman with a COC-associated distal DVT received therapeutic anticoagulation for a median of 3 months. At 3-year follow-up, all women with COC-associated distal DVTs were alive, and none had bled during anticoagulant treatment or had experienced a DVT or PE recurrence after stopping anticoagulants. Similar results were found in patients with COC-associated proximal DVT and PE: The VTE recurrence rate was 1.7% per patient-year (PY) and 0% PY, respectively, and there were no deaths or major bleeds in either group. CONCLUSIONS Distal DVT was the most frequent clinical presentation of COC-associated VTE and had similarly favorable long-term outcomes as other COC-associated VTE.
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Affiliation(s)
- Jean‐Philippe Galanaud
- Department of Vascular Medicine and Clinical Investigation CentreMontpellier University HospitalMontpellierFrance
- Department of MedicineSunnybrook Health Sciences CentreUniversity of TorontoTorontoONCanada
| | | | - Gilles Pernod
- Department of Public HealthCNRSGrenoble‐Alpes University Hospital and TIMC‐IMAGUniversity Grenoble AlpesGrenobleFrance
- Department of Vascular MedicineGrenoble‐Alpes University HospitalGrenobleFrance
| | - Céline Genty
- Department of Public HealthCNRSGrenoble‐Alpes University Hospital and TIMC‐IMAGUniversity Grenoble AlpesGrenobleFrance
| | - Cécile Richaud
- Department of Vascular MedicineGrenoble‐Alpes University HospitalGrenobleFrance
| | - Carole Rolland
- Department of Public HealthCNRSGrenoble‐Alpes University Hospital and TIMC‐IMAGUniversity Grenoble AlpesGrenobleFrance
| | - Laurence Weber
- Vascular Medicine PhysicianAvignon HospitalAvignonFrance
| | - Susan R. Kahn
- Department of MedicineMcGill UniversityMontrealQCCanada
- Centre for Clinical EpidemiologyJewish General HospitalMontrealQCCanada
| | - Isabelle Quéré
- Department of Vascular Medicine and Clinical Investigation CentreMontpellier University HospitalMontpellierFrance
| | - Jean‐Luc Bosson
- Department of Public HealthCNRSGrenoble‐Alpes University Hospital and TIMC‐IMAGUniversity Grenoble AlpesGrenobleFrance
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26
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Kim WJ, Kim J, Kang M, Park DH, Jeon JY. Usefulness of computed tomography venography in gynecologic cancer patients with lower extremity edema. Medicine (Baltimore) 2020; 99:e21818. [PMID: 32925718 PMCID: PMC7489682 DOI: 10.1097/md.0000000000021818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Lower extremity (LEx) edema is a common complication in gynecologic cancer patients. There are 2 main causes of edema in these patients such as deep vein thrombosis (DVT) and lymphedema. Early diagnosis and treatment of DVT are certainly important, but it is often difficult to evaluate proximal DVT by using ultrasound. The aim of this study is to demonstrate the usefulness of computed tomography venography of the lower extremity (CTV LEx) for the diagnosis of the DVT and investigate predictive factor of DVT in gynecologic cancer patients with LEx edema.The medical records of 415 gynecologic cancer patients who were referred to the department of rehabilitation medicine with LEx edema were retrospectively reviewed in this case-controlled study. We categorized CTV LEx findings as follows: DVT proximal to the inguinal ligament (inferior vena cava or iliac vein thrombosis) and DVT distal to the inguinal ligament (femoral, popliteal, or calf vein thrombosis). We also evaluated patient characteristics including D-dimer level. We analyzed the correlation of each factor with DVT frequency and used receiver operating characteristic curve analysis to determine the appropriate D-dimer threshold.Sixty-six patients were diagnosed with DVT; of them, 35 (53%) had DVT proximal to the inguinal ligament. Twenty-two patients were diagnosed with pulmonary embolism, of whom 15 had proximal DVT. Patients with proximal DVT tended to have pulmonary embolism (P < .001). Distal organ metastasis (odds ratio [OR], 2.88; P = .002) and a high D-dimer level (OR, 1.13; P = .001) were correlated with DVT.CTV LEx is a useful diagnostic tool for gynecologic cancer patients with LEx edema, particularly high-risk patients, that should be performed at the initial evaluation.
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27
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Kuczmik W, Wysokinski WE, Hesley GK, Vlazny DT, Houghton DE, Swanson KE, Casanegra AI, Hodge D, White L, McBane RD. Calf Vein Thrombosis Comparison of Outcomes for Axial and Muscular Venous Thrombosis. Thromb Haemost 2020; 121:216-223. [PMID: 32828073 DOI: 10.1055/s-0040-1715646] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The objective of this study was to characterize clinical features and outcomes among patients with calf deep vein thrombosis (DVT) limited to the muscular veins compared with axial veins. METHODS Consecutive patients with ultrasound confirmed acute DVT involving the calf veins (January 1, 2016-August 1, 2018) were identified from the Gonda Vascular Center ultrasound database. Patients were divided into axial or muscular groups based on thrombus location. Demographics, management, and outcomes were compared. RESULTS Over the study period, there were 647 patients with calf DVT equally distributed between axial (n = 321) and muscular (n = 326) locations. Within these groups, peroneal and soleal veins were most commonly involved. Nearly all cases were provoked (97%). Synchronous pulmonary embolism (PE) were more common for axial (30.8%) compared to muscular groups (20.2%; p = 0.001); nearly one-third had no pulmonary symptoms. Anticoagulation for a median of 3 months was initiated for 85.5% of both groups. Venous thromboembolism (VTE) recurrence was more common in the axial group (15.9% vs. 7.1%, p = 0.0015) including more frequent DVT propagation (9.4% vs. 3.1%; p = 0.0017) and PE (3.4% vs. 0.6%; p = 0.0168). Major bleeding, clinically relevant nonmajor bleeding, and mortality rates did not differ between groups. Withholding anticoagulation led to more frequent thrombus propagation in the axial group (3.4% vs. 0.9%; p = 0.029). CONCLUSION Several important features distinguish muscular from axial DVT. Axial DVT are more likely to have an associated PE and are more likely to experience recurrent VTE, particularly if anticoagulation is withheld.
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Affiliation(s)
- Wiktoria Kuczmik
- Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, United States
| | - Waldemar E Wysokinski
- Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, United States.,Cardiovascular Department, Mayo Clinic, Rochester, Minnesota, United States
| | - Gina K Hesley
- Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, United States
| | - Danielle T Vlazny
- Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, United States.,Cardiovascular Department, Mayo Clinic, Rochester, Minnesota, United States
| | - Damon E Houghton
- Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, United States.,Cardiovascular Department, Mayo Clinic, Rochester, Minnesota, United States
| | - Keith E Swanson
- Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, United States.,Cardiovascular Department, Mayo Clinic, Rochester, Minnesota, United States
| | - Ana I Casanegra
- Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, United States.,Cardiovascular Department, Mayo Clinic, Rochester, Minnesota, United States
| | - David Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida, United States
| | - Launia White
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida, United States
| | - Robert D McBane
- Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, United States.,Cardiovascular Department, Mayo Clinic, Rochester, Minnesota, United States
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28
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Abstract
Summary. Isolated distal deep vein thromboses (IDDVT) represent up to 50 % of legs deep vein thromboses (DVT). However, since their natural history is to date unknown, the need to diagnose and treat them is a matter of debate. The diagnostic strategy based on the assessment of pre-test probability and D-dimer demonstrated a scarse efficiency for IDDVT. The choice between a proximal and a complete ultrasonographic approach should be guided by the clinical context, the local expertise and the patient characteristics. Randomized and observational studies have analyzed the need of therapy and compared different regimens of anticoagulation, with conflicting results. Systematic reviews and meta-analyses tend to support the usefulness of an anticoagulant treatment, even if the optimal dose and duration are not still defined. A careful stratification of the patient’s profile, taking into account risk factors for proximal extension, recurrence and bleeding should address the therapeutic approach, which must always be discussed with an adequately informed patient. Further studies aimed to clarify the natural history of IDDVT, and to assess safety and efficacy of lower intensity and shorter duration protocols are urgently needed.
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Affiliation(s)
- Giovanna Elmi
- Medical Department, Ultrasound Program, Maggiore Hospital, Azienda USL of Bologna, Italy
| | - Elisa Rebecca Rinaldi
- Medical Department, Ultrasound Program, Maggiore Hospital, Azienda USL of Bologna, Italy
| | - Andrea Domanico
- Medical Department, Ultrasound Program, Maggiore Hospital, Azienda USL of Bologna, Italy
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Nicholson M, Chan N, Bhagirath V, Ginsberg J. Prevention of Venous Thromboembolism in 2020 and Beyond. J Clin Med 2020; 9:jcm9082467. [PMID: 32752154 PMCID: PMC7465935 DOI: 10.3390/jcm9082467] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/18/2020] [Accepted: 07/27/2020] [Indexed: 02/06/2023] Open
Abstract
Venous thromboembolism (VTE) is the third most common cause of vascular mortality worldwide and comprises deep-vein thrombosis (DVT) and pulmonary embolism (PE). In this review, we discuss how an understanding of VTE epidemiology and the results of thromboprophylaxis trials have shaped the current approach to VTE prevention. We will discuss modern thromboprophylaxis as it pertains to genetic risk factors, exogenous hormonal therapies, pregnancy, surgery, medical hospitalization, cancer, and what is known thus far about VTE in COVID-19 infection.
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Asonitis K, Charvalos E, Lambert C, Hermans C. Experience of a 40-day (6 week) LMWH treatment for isolated distal deep vein thrombosis. J Thromb Thrombolysis 2020; 50:837-843. [PMID: 32189191 DOI: 10.1007/s11239-020-02089-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Clinical significance of distal deep vein thrombosis (DVT) is important as it can potentially result in pulmonary embolism (PE), DVT extension, DVT recurrence and post-thrombotic syndrome (PTS). Controversy remains about the necessity and modalities of anticoagulation in all distal DVT. Evaluation of the efficiency of a 40-day weight-based low molecular weight heparin (LMWH) treatment in a cohort of 119 consecutive patients with distal DVT. Compression ultrasonography of the lower limb was performed initially for diagnosis as well as at the end of the treatment to identify persistence or resolution of the blood clot. A 3-month follow-up estimated the rates of PE, DVT recurrence, DVT extension, PTS and bleeding. Risk factors for DVT were considered to evaluate a possible correlation between them and the outcomes. In 71.4% of the patients the blood clot was totally dissolved and thrombus persistence was statistically associated with the number of initially involved veins. DVT recurrence occurred in 5% of patients and was also associated with the number of initial clotted veins. DVT extension and PTS rates were present in 1.7% and 3.4% respectively and no patient was diagnosed with PE or bleeding. This retrospective study including a limited number of patients and no control group supports that a 40-day weight-based LMWH treatment after distal DVT seems to be efficient when one single vein is initially affected whereas for multiple vein distal DVT and to avoid potential DVT recurrence, longer than 6 weeks of anticoagulant treatment is required. Our results support safety of the treatment, its potential to prevent DVT extension and the occurrence of PE.
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Affiliation(s)
- Konstantinos Asonitis
- Division of Haematology, Haemostasis and Thrombosis Unit, Cliniques Universitaires Saint-Luc (UCL), Université Catholique de Louvain, 10 Avenue Hippocrate, 1200, Brussels, Belgium.
| | | | - Catherine Lambert
- Division of Haematology, Haemostasis and Thrombosis Unit, Cliniques Universitaires Saint-Luc (UCL), Université Catholique de Louvain, 10 Avenue Hippocrate, 1200, Brussels, Belgium
| | - Cedric Hermans
- Division of Haematology, Haemostasis and Thrombosis Unit, Cliniques Universitaires Saint-Luc (UCL), Université Catholique de Louvain, 10 Avenue Hippocrate, 1200, Brussels, Belgium
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31
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Poudel SK, Park DY, Jia X, Wilks M, Pinkava V, O'Brien M, Tripp B, Song JM, McCrae KR, Khorana AA, Angelini DE. Clinical outcomes of isolated distal deep vein thrombosis versus proximal venous thromboembolism in cancer patients: The Cleveland Clinic experience. J Thromb Haemost 2020; 18:651-659. [PMID: 31808607 DOI: 10.1111/jth.14700] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 11/25/2019] [Accepted: 11/27/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Previous studies suggest isolated distal deep vein thrombosis (IDDVT) has a self-limited clinical course. However, these studies excluded cancer patients, who remain a high-risk population. In addition, studies to evaluate the long-term clinical outcomes of IDDVT in cancer patients have been limited. Here, we report outcomes from our experience in treating cancer-associated IDDVT versus proximal venous thromboembolism (VTE). METHODS We prospectively evaluated a cohort of patients referred to our cancer-associated thrombosis clinic from August 2014 through May 2018. We compared clinical characteristics, anticoagulation prescription, VTE recurrence, overall survival, major bleeding, and subsequent hospital admission between cancer patients with IDDVT and proximal VTE. A propensity score matching method was used to reduce bias from confounding variables. RESULTS Of 1100 patients referred to the clinic, 124 IDDVT and 178 proximal VTE events were analyzed. After propensity score matching, 96 patients were included in each cohort. There was no difference in the rate of recurrent VTE between cancer patients with proximal VTE vs IDDVT, with or without matching (matched: hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.31-1.92; P = .58). There was no difference in overall survival between cancer patients with proximal VTE vs. IDDVT with or without matching (matched: HR, 1.18; 95% CI, 0.77-1.82; P = .45). Furthermore, subsequent hospital admissions and major bleeding events were similar between patients with proximal VTE events versus IDDVT. CONCLUSIONS Cancer patients with IDDVT have similar outcomes as their proximal counterparts, including rate of recurrence and overall survival. These findings suggest treatment of cancer-associated IDDVT should mirror treatment of proximal events.
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Affiliation(s)
- Shyam K Poudel
- Department of Internal Medicine, Western Reserve Health Education, Youngstown, Ohio
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Deborah Y Park
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Xuefei Jia
- Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mailey Wilks
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vicki Pinkava
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Meghan O'Brien
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Barbara Tripp
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jung-Min Song
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Keith R McCrae
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alok A Khorana
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dana E Angelini
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
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Quéré I, Galanaud JP, Sanchez O. [What is the management of sub-popliteal deep venous thrombosis?]. Rev Mal Respir 2019; 38 Suppl 1:e164-e170. [PMID: 31611025 DOI: 10.1016/j.rmr.2019.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- I Quéré
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Département de médecine vasculaire, centre de référence des maladies vasculaires rares, EA2992, université de Montpellier, CHU Montpellier, hôpital Saint-Éloi, 34295 Montpellier cedex 5, France
| | - J P Galanaud
- Département de médecine vasculaire, centre de référence des maladies vasculaires rares, EA2992, université de Montpellier, CHU Montpellier, hôpital Saint-Éloi, 34295 Montpellier cedex 5, France; Department of medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - O Sanchez
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Inserm UMRS 1140, service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, Assistance publique des Hôpitaux de Paris, université Paris Descartes, Sorbonne Paris cité, 75015 Paris, France; Service de pneumologie et soins intensifs, université de Paris, AH-HP, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Innovations thérapeutiques en hémostase, Inserm UMRS 1140, 75006 Paris, France.
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Ageno W, Mantovani LG, Haas S, Kreutz R, Monje D, Schneider J, Bugge JP, Gebel M, Turpie AGG. Patient Management Strategies and Long-Term Outcomes in Isolated Distal Deep-Vein Thrombosis versus Proximal Deep-Vein Thrombosis: Findings from XALIA. TH Open 2019; 3:e85-e93. [PMID: 31249987 PMCID: PMC6524913 DOI: 10.1055/s-0039-1683968] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 02/06/2019] [Indexed: 02/04/2023] Open
Abstract
Background
Overall, 30 to 50% of lower-limb deep-vein thrombosis (DVT) cases are isolated distal DVT (IDDVT). The recurrent venous thromboembolism (VTE) risk is unclear, leaving uncertainty over optimal IDDVT treatment. We present data on patients with IDDVT and proximal DVT (PDVT) from the prospective, noninterventional XALIA study of rivaroxaban for acute and extended VTE treatment.
Methods
Patients aged ≥18 years scheduled to receive ≥3 months' anticoagulation with rivaroxaban or standard anticoagulation were eligible, with follow-up for ≥12 months. We describe baseline characteristics, management strategies, and incidence proportions of VTE recurrence, major bleeding, and all-cause mortality in patients with IDDVT or PDVT, with or without distal vein involvement.
Findings
Overall, 1,004 patients with IDDVT and 3,098 with PDVT were enrolled; 641 (63.8%) and 1,683 (54.3%) received rivaroxaban, respectively. Patients with IDDVT were younger and had lower incidences of renal impairment, cancer, and unprovoked VTE than those with PDVT. On-treatment recurrence incidences for IDDVT versus PDVT were 1.0 versus 2.4% (adjusted hazard ratio [HR]: 0.56; 95% confidence interval [CI]: 0.29–1.08), and incidences posttreatment cessation were 1.1 versus 2.1% (adjusted HR: 0.65; 95% CI: 0.32–1.35), respectively. On-treatment major bleeding incidences were 0.9 versus 1.4% and mortality was 0.8 versus 2.2%, respectively. Median treatment duration in patients with IDDVT was shorter than in those with PDVT (102 vs. 192 days, respectively).
Interpretation
Patients with IDDVT had fewer comorbidities and were more frequently treated with rivaroxaban than those with PDVT. On-treatment and posttreatment recurrences were less frequent in patients with IDDVT.
Trial registration number:
NCT01619007.
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Affiliation(s)
- Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Lorenzo G Mantovani
- CESP-Center for Public Health Research, University of Milano-Bicocca, Monza, Italy
| | - Sylvia Haas
- Formerly Institute for Experimental Oncology and Therapy Research, Technical University of Munich, Munich, Germany
| | - Reinhold Kreutz
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
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Valerio L, Ambaglio C, Barone M, Ciola M, Konstantinides SV, Mahmoudpour SH, Picchi C, Pieresca C, Trinchero A, Barco S. Recurrence Risk after First Symptomatic Distal versus Proximal Deep Vein Thrombosis According to Baseline Risk Factors. TH Open 2019; 3:e58-e63. [PMID: 31249983 PMCID: PMC6524909 DOI: 10.1055/s-0039-1683374] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 01/30/2019] [Indexed: 12/26/2022] Open
Abstract
Background
It remains unclear whether the distal location of deep vein thrombosis (DVT) is independently associated with a lower risk of recurrence in all patients, or represents a marker of the presence and severity of provoking factors for venous thromboembolism (VTE).
Methods
We investigated the impact of distal (vs. proximal) DVT location on the risk of developing symptomatic, objectively confirmed recurrent VTE in 831 patients with a first acute symptomatic DVT not associated with pulmonary embolism (PE), who were stratified by the presence of transient or persistent risk factors at baseline. The primary outcome was symptomatic, objectively diagnosed recurrent VTE, including proximal DVT and PE.
Results
A total of 205 (24.7%) patients presented with a transient risk factor, 189 (22.7%) with a minor persistent risk factor, 202 (24.3%) with unprovoked DVT, and 235 (28.3%) with cancer-associated DVT. One-hundred twenty-five patients (15.0%) experienced recurrent DVT or PE. The largest relative difference between patients with distal (vs. proximal) DVT was observed in the absence of identifiable risk factors (adjusted hazard ratio [aHR]: 0.11; 95% CI [confidence interval]: 0.03–0.45). In patients with cancer, distal and proximal DVT had a comparable risk of recurrence (aHR: 0.70; 95% CI: 0.28–1.78]).
Conclusions
The distal (vs. proximal) location of first acute symptomatic DVT represented, in the absence of any identifiable transient or persistent risk factors, a favorable prognostic factor for recurrence. In contrast, the prognostic impact of DVT location was weaker if persistent provoking risk factors for VTE were present, notably cancer.
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Affiliation(s)
- Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University-Mainz, Mainz, Germany
| | - Chiara Ambaglio
- Department of Internal Medicine, Fondazione IRCCS Policlinico "San Matteo," Pavia, Italy
| | - Marisa Barone
- Thromboembolic Disease Unit, Istituti Clinici Scientifici Spa SB IRCCS Maugeri, Pavia, Italy
| | - Mariella Ciola
- Department of Internal Medicine, Fondazione IRCCS Policlinico "San Matteo," Pavia, Italy
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University-Mainz, Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Seyed H Mahmoudpour
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University-Mainz, Mainz, Germany.,Department of Biometry and Bioinformatics, Institute for Medical Biostatistics, Epidemiology, and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Chiara Picchi
- Department of Internal Medicine, Presidio Ospedaliero "Macedonio Melloni" ASST FBF "Sacco," Milano, Italy
| | - Carla Pieresca
- Department of Internal Medicine, Fondazione IRCCS Policlinico "San Matteo," Pavia, Italy
| | - Alice Trinchero
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University-Mainz, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University-Mainz, Mainz, Germany
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Hsu C, Brahmandam A, Brownson KE, Huynh N, Reynolds J, Lee AI, Fares WH, Ochoa Chaar CI. Statin therapy associated with improved thrombus resolution in patients with deep vein thrombosis. J Vasc Surg Venous Lymphat Disord 2019; 7:169-175.e4. [DOI: 10.1016/j.jvsv.2018.10.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 10/24/2018] [Indexed: 10/27/2022]
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Quéré I, Elias A, Maufus M, Elias M, Sevestre MA, Galanaud JP, Bosson JL, Bura-Rivière A, Jurus C, Lacroix P, Zuily S, Diard A, Wahl D, Bertoletti L, Brisot D, Frappe P, Gillet JL, Ouvry P, Pernod G. [Unresolved questions on venous thromboembolic disease. Consensus statement of the French Society for Vascular Medicine (SFMV)]. J Med Vasc 2019; 44:e1-e47. [PMID: 30770089 DOI: 10.1016/j.jdmv.2018.12.178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- I Quéré
- Service de médecine vasculaire, CHU Montpellier, 80, avenue Augustun-Fliche, 34090 Montpellier, France
| | - A Elias
- Service de médecine vasculaire, CH Sainte Musse, 83100 Toulon, France
| | - M Maufus
- Service de médecine vasculaire, CH Pierre Oudot, 38300 Bourgoin-Jallieu, France
| | - M Elias
- Service de médecine vasculaire, CH Sainte Musse, 83100 Toulon, France
| | - M-A Sevestre
- Service de médecine vasculaire, CHU Amiens-Picardie, Avenue Laennec, 80054 Amiens cedex 1, France
| | - J-P Galanaud
- Département de médecine, Sunnybrook Health Sciences Centre, université de Toronto, Toronto, Canada
| | - J-L Bosson
- Département de biostatistiques, CHU Grenoble-Alpes, 38043 Grenoble, France
| | - A Bura-Rivière
- Service de médecine vasculaire, CHU Rangueil, 31059 Toulouse cedex 9, France
| | - C Jurus
- Service de médecine vasculaire, clinique du Tonkin, 69100 Villeurbanne, France
| | - P Lacroix
- Service de médecine vasculaire, Hôpital Dupuytren, CHU Limoges, 87042 Limoges cedex, France
| | - S Zuily
- Service de médecine vasculaire, Hôpital Brabois, CHU Nancy, 54511 Vandoeuvre-Les-Nancy cedex, France
| | - A Diard
- Médecine vasculaire, 25, route de Créon, 33550 Langoiran, France
| | - D Wahl
- Service de médecine vasculaire, Hôpital Brabois, CHU Nancy, 54511 Vandoeuvre-Les-Nancy cedex, France
| | - L Bertoletti
- Service de médecine vasculaire et thérapeutique, Hôpital Nord, CHU St-Étienne, 42, avenue Albert Raimond, 42270 Saint-Priest-en-Jarez, France
| | - D Brisot
- Médecine vasculaire, 34830 Clapiers, France
| | - P Frappe
- Département de médecine générale, université Jean-Monnet, 42000 St-Étienne, France
| | - J-L Gillet
- Médecine vasculaire, 38300 Bourgoin-Jallieu, France
| | - P Ouvry
- Médecine vasculaire, 1328, avenue de la Maison Blanche, 76550 Saint-Aubin-sur-Scie, France
| | - G Pernod
- Service de médecine vasculaire, CHU Grenoble-Alpes, 38043 Grenoble, France.
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Quéré I, Elias A, Maufus M, Elias M, Sevestre MA, Galanaud JP, Bosson JL, Bura-Rivière A, Jurus C, Lacroix P, Zuily S, Diard A, Wahl D, Bertoletti L, Brisot D, Frappe P, Gillet JL, Ouvry P, Pernod G. Unresolved questions on venous thromboembolic disease. Consensus statement of the French Society for Vascular Medicine (SFMV). J Med Vasc 2019; 44:28-70. [PMID: 30770082 DOI: 10.1016/j.jdmv.2018.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 12/01/2018] [Indexed: 06/09/2023]
Affiliation(s)
- I Quéré
- Service de médecine vasculaire, CHU Montpellier, 80, avenue Augustun-Fliche, 34090 Montpellier, France
| | - A Elias
- Service de médecine vasculaire, CH Sainte Musse, 83100 Toulon, France
| | - M Maufus
- Service de médecine vasculaire, CH Pierre Oudot, 38300 Bourgoin-Jallieu, France
| | - M Elias
- Service de médecine vasculaire, CH Sainte Musse, 83100 Toulon, France
| | - M-A Sevestre
- Service de médecine vasculaire, CHU Amiens Picardie, avenue Laennec, 80054 Amiens cedex 1, France
| | - J-P Galanaud
- Département de médecine, Sunnybrook Health Sciences Centre, université de Toronto, Toronto, Canada
| | - J-L Bosson
- Département de biostatistiques, CHU Grenoble-Alpes, 38700 La Tronche, France
| | - A Bura-Rivière
- Service de médecine vasculaire, CHU Rangueil, 31059 Toulouse cedex 9, France
| | - C Jurus
- Service de médecine vasculaire, clinique du Tonkin, 69100 Villeurbanne, France
| | - P Lacroix
- Service de médecine vasculaire, hôpital Dupuytren, CHU Limoges, 87042 Limoges cedex, France
| | - S Zuily
- Service de médecine vasculaire, hôpital Brabois, CHU Nancy, 54511 Vandoeuvre-les-Nancy cedex, France
| | - A Diard
- Médecine vasculaire, 25, route de Créon, 33550 Langoiran, France
| | - D Wahl
- Service de médecine vasculaire, hôpital Brabois, CHU Nancy, 54511 Vandoeuvre-les-Nancy cedex, France
| | - L Bertoletti
- Service de médecine vasculaire et thérapeutique, hôpital Nord, CHU St.-Étienne, 42, avenue Albert-Raimond, 42270 Saint-Priest-en-Jarez, France
| | - D Brisot
- Médecine vasculaire, 34830 Clapiers, France
| | - P Frappe
- Département de médecine générale, université Jean-Monnet, 42000 St.-Étienne, France
| | - J-L Gillet
- Médecine vasculaire, 1328, avenue Maison-Blanche, 38300 Bourgoin-Jallieu, France
| | - P Ouvry
- Médecine vasculaire, 1328, avenue Maison-Blanche, 76550 Saint-Aubin-sur-Scie, France
| | - G Pernod
- Service de médecine vasculaire, CHU Grenoble-Alpes, avenue Maquis-du-Grésivaudan, 38043 Grenoble, France.
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Trinchero A, Scheres LJ, Prochaska JH, Ambaglio C, Wild PS, Middeldorp S, Konstantinides SV, Barco S. Sex-specific differences in the distal versus proximal presenting location of acute deep vein thrombosis. Thromb Res 2018; 172:74-79. [DOI: 10.1016/j.thromres.2018.10.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 09/27/2018] [Accepted: 10/24/2018] [Indexed: 01/05/2023]
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Affiliation(s)
- Andrea Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, 5372 Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA.
| | - Thomas Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, 5463 Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA
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Abstract
Aim In this study, we aimed to analyze the genetic and acquired risk factors for deep vein thrombosis (DVT) of the lower extremities among Sudanese women. Methods A total of 136 women were enrolled in the study, including 75 DVT patients and 61 healthy controls. Demographic and clinical data were collected using a specific questionnaire. Citrated blood samples of patients and controls were used for coagulation assays, and DNAs isolated from EDTA-blood samples were used for the detection of Factor V Leiden and prothrombin G20210A mutations using multiplex polymerase chain reaction-restriction fragment length polymorphism analysis. Results Both gene mutations were found to be absent from all 136 subjects, and therefore did not account for the incidence of DVT in Sudanese women. Of the 75 DVTs, 70 (93.3%) were localized in the left leg and 5 (6.7%) in the right leg. Additionally, 84% of the DVTs were proximal and 16% were distal. Among the 75 patients, 22 (29.33%) were postpartum, 7 (9.33%) were pregnant, and 46 (61.33%) were nonpregnant. Levels of prothrombin fragment 1+2, prothrombin time, activated partial thromboplastin time, and D-dimer were significantly higher in DVT patients than in healthy controls (P<0.0001). Conclusion Risk factors that most significantly affected patients in the 18–45 years age group were pregnancy and oral contraceptive usage, whereas those that most significantly affected patients in the 66–90 years age group were immobility, heart disease, and history of DVT.
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Affiliation(s)
- Nadir Ahmed Ibrahim
- Department of Hematology and Immunohematology, College of Medical Laboratory Science, Sudan University of Science and Technology, Khartoum, Sudan, .,Department of Clinical Laboratory Sciences, Faculty of Applied Medical Sciences, Taibah University, Medina, Saudi Arabia,
| | - Fathelrahman M Hassan
- Department of Clinical Laboratory Science, College of Applied Medical Science, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mahmoud Mohamed Elgari
- Department of Clinical Laboratory Sciences, Faculty of Applied Medical Sciences, Taibah University, Medina, Saudi Arabia,
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Affiliation(s)
| | - Iva Golemi
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Luis H Paz
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL
| | - Luis Diaz Quintero
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Alfonso J Tafur
- Cardiovascular Section, NorthShore University HealthSystem, 2650 Ridge Ave, Evanston, IL 60201.
| | - Joseph A Caprini
- The University of Chicago Pritzker School of Medicine, Chicago, IL
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Prell J, Schenk G, Taute BM, Scheller C, Marquart C, Strauss C, Rampp S. Reduced risk of venous thromboembolism with the use of intermittent pneumatic compression after craniotomy: a randomized controlled prospective study. J Neurosurg 2018; 130:622-628. [PMID: 29600912 DOI: 10.3171/2017.9.jns17533] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 09/25/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The term "venous thromboembolism" (VTE) subsumes deep venous thrombosis (DVT) and pulmonary embolism. The incidence of DVT after craniotomy was reported to be as high as 50%. Even clinically silent DVT may lead to potentially fatal pulmonary embolism. The risk of VTE is correlated with duration of surgery, and it appears likely that it develops during surgery. The present study aimed to evaluate intraoperative use of intermittent pneumatic compression (IPC) of the lower extremity for prevention of VTE in patients undergoing craniotomy. METHODS A total of 108 patients undergoing elective craniotomy for intracranial pathology were included in a single-center controlled randomized prospective study. In the control group, conventional compression stockings were worn during surgery. In the treatment group, IPC of the calves was used in addition. The presence of DVT was evaluated by Doppler sonography pre- and postoperatively. RESULTS Intraoperative use of IPC led to a significant reduction of VTE (p = 0.029). In logistic regression analysis, the risk of VTE was approximately quartered by the use of IPC. Duration of surgery was confirmed to be correlated with VTE incidence (p < 0.01); every hour of surgery increased the risk by a factor of 1.56. CONCLUSIONS Intraoperative use of IPC significantly lowers the incidence of potentially fatal VTE in patients undergoing craniotomy. The method is easy to use and carries no additional risks.■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: randomized controlled trial; evidence: class I.Clinical trial registration no.: DRKS00011783 (https://www.drks.de).
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Patel K, Chagin K, Tunsupon P, Yampikulsakul P, Shah GV, Wangsiricharoen S, Amah L, Allen J, Shapiro A, Gupta N, Morgan L, Kumar R, Nielsen C, Rothberg MB, Brateanu A. Probability of developing proximal deep-vein thrombosis and/or pulmonary embolism after distal deep-vein thrombosis. Thromb Haemost 2018; 115:608-14. [DOI: 10.1160/th15-06-0503] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 11/05/2015] [Indexed: 11/05/2022]
Abstract
SummaryIsolated distal deep-vein thrombosis (DDVT) of the lower extremities can be associated with subsequent proximal deep-vein thrombosis (PDVT) and/or acute pulmonary embolism (PE). We aimed to develop a model predicting the probability of developing PDVT and/or PE within three months after an isolated episode of DDVT. We conducted a retrospective cohort study of patients with symptomatic DDVT confirmed by lower extremity vein ultrasounds between 2001–2012 in the Cleveland Clinic Health System. We reviewed all the ultrasounds, chest ventilation/perfusion and computed tomography scans ordered within three months after the initial DDVT to determine the incidence of PDVT and/or PE. A multiple logistic regression model was built to predict the rate of developing these complications. The final model included 450 patients with isolated DDVT. Within three months, 30 (7%) patients developed an episode of PDVT and/or PE. Only two factors predicted subsequent thromboembolic complications: inpatient status (OR, 6.38; 95 % CI, 2.17 to 18.78) and age (OR, 1.02 per year; 95 % CI, 0.99 to 1.05). The final model had a bootstrap bias-corrected c-statistic of 0.72 with a 95 % CI (0.64 to 0.79). Outpatients were at low risk (<4 %) of developing PDVT/PE. Inpatients aged ≥ 60 years were at high risk (> 10%). Inpatients aged < 60 were at intermediate risk. We created a simple model that can be used to risk stratify patients with isolated DDVT based on inpatient status and age. The model might be used to choose between anticoagulation and monitoring with serial ultrasounds.
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Garcia R, Probeck K, Elitharp DM, Gasparis AP, Labropoulos N. Diverse management of isolated calf deep venous thrombosis in a university hospital. J Vasc Surg Venous Lymphat Disord 2018; 6:139-145. [DOI: 10.1016/j.jvsv.2017.08.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 08/25/2017] [Indexed: 10/18/2022]
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Li S, Feng L, Xiao M, Chen S, He J, Wang Z. Derivation and Validation of a Clinical Prediction Scale for Isolated Distal Deep Venous Thrombosis in Patients after Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2017; 26:2087-92. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.04.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Dentali F, Pegoraro S, Barco S, di Minno MND, Mastroiacovo D, Pomero F, Lodigiani C, Bagna F, Sartori M, Barillari G, Mumoli N, Napolitano M, Passamonti SM, Benedetti R, Ageno W, Di Nisio M. Clinical course of isolated distal deep vein thrombosis in patients with active cancer: a multicenter cohort study. J Thromb Haemost 2017; 15:1757-1763. [PMID: 28639418 DOI: 10.1111/jth.13761] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Indexed: 11/28/2022]
Abstract
Essentials Isolated distal deep vein thrombosis (IDDVT) is frequently associated with cancer. No study has specifically evaluated the long-term clinical course of cancer-associated IDDVT. Patients with cancer-associated IDDVT are at very high risk of symptomatic recurrence and death. We observed low rates of major bleeding during anticoagulation. SUMMARY Background Although isolated distal deep vein thrombosis (IDDVT) is frequently associated with cancer, no study has specifically evaluated the long-term clinical course of IDDVT in this setting. Aim To provide data on the rate of recurrent venous thromboembolism (VTE), major bleeding events and death in IDDVT patients with active cancer. Patients and Methods Consecutive patients with active cancer and an objective IDDVT diagnosis (January 2011 to September 2014) were included from our files. We collected information on baseline characteristics, IDDVT location and extension, VTE risk factors, and type and duration of anticoagulant treatment. Results A total of 308 patients (mean age 66.2 [standard deviation (SD), 13.2 years]; 57.1% female) with symptomatic IDDVT and a solid (n = 261) or hematologic (n = 47) cancer were included at 13 centers. Cancer was metastatic in 148 (48.1%) patients. All but three (99.0%) patients received anticoagulant therapy, which consisted of low-molecular-weight heparin in 288 (93.5%) patients. Vitamin K antagonists were used for the long-term treatment in 46 (14.9%) patients, whereas all others continued the initial parenteral agent for a mean treatment duration of 4.2 months (SD, 4.6 months). During a total follow-up of 355.8 patient-years (mean, 13.9 months), there were 47 recurrent objectively diagnosed VTEs for an incidence rate of 13.2 events per 100 patient-years. During anticoagulant treatment, the annual incidence of major bleeding was 2.0 per 100 patient-years. Conclusions Cancer patients with IDDVT have a high risk of VTE recurrence. Additional studies are warranted to investigate the optimal intensity and duration of anticoagulant treatment for these patients.
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Affiliation(s)
- F Dentali
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - S Pegoraro
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - S Barco
- Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - M N D di Minno
- Department of Advanced Biomedical Sciences, Unit of Cardiology, Federico II University, Naples, Italy
| | | | - F Pomero
- Department of Internal Medicine, S. Croce e Carle General Hospital, Cuneo, Italy
| | - C Lodigiani
- Thrombosis Center, IRCCS Istituto Clinico Humanitas, Rozzano-Milano, Italy
| | - F Bagna
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - M Sartori
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - G Barillari
- Center for Haemorrhagic and Thrombotic Disorders, Udine General and University Hospital, Udine, Italy
| | - N Mumoli
- Department of Internal Medicine, Ospedale Civile Livorno, Livorno, Italy
| | - M Napolitano
- Haemophilia and Thrombosis Centre, Haematology Department, University of Palermo, Palermo, Italy
| | - S M Passamonti
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - R Benedetti
- Haemostasis and Thrombosis Center, Department of Internal Medicine, Hospital of Piacenza, Piacenza, Italy
| | - W Ageno
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - M Di Nisio
- Department of Medical, Oral and Biotechnological Sciences, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy
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Barnes GD. Preventing recurrence from distal deep vein thrombosis: Still searching for answers. Vasc Med 2017; 22:525-526. [PMID: 28835172 DOI: 10.1177/1358863x17727065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Geoffrey D Barnes
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
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Donadini MP, Dentali F, Pegoraro S, Pomero F, Brignone C, Guasti L, Steidl L, Ageno W. Long-term recurrence of venous thromboembolism after short-term treatment of symptomatic isolated distal deep vein thrombosis: A cohort study. Vasc Med 2017; 22:518-524. [DOI: 10.1177/1358863x17720531] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Isolated distal deep vein thrombosis (IDDVT) is a common clinical manifestation of venous thromboembolism (VTE). However, there are only scant and heterogeneous data available on the long-term risk of recurrent VTE after IDDVT, and the optimal therapeutic management remains uncertain. We carried out a retrospective cohort study of consecutive patients diagnosed with symptomatic IDDVT between 2004 and 2011, according to a predefined short-term treatment protocol (low molecular weight heparin (LMWH) for 4–6 weeks). The primary outcome was the occurrence of recurrent VTE. A total of 321 patients were enrolled. IDDVT was associated with a transient risk factor or cancer in 165 (51.4%) and 56 (17.4%) patients, respectively. LMWH was administered for 4–6 weeks to 280 patients (87.2%), who were included in the primary analysis. Overall, during a mean follow-up of 42.3 months, 42 patients (15%) developed recurrent VTE, which occurred as proximal DVT or PE in 21 cases. The recurrence rate of VTE per 100 patient-years was 3.5 in patients with transient risk factors, 7.2 in patients with unprovoked IDDVT, and 5.9 in patients with cancer ( p=0.018). At multivariable analysis, unprovoked IDDVT and previous VTE were significantly associated with recurrent VTE (HR 2.16, 95% CI 1.12–4.16 and HR 1.97, 95% CI 1.01–3.86, respectively). In conclusion, the long-term risk of recurrent VTE after IDDVT treated for 4–6 weeks is not negligible, in particular in patients with unprovoked IDDVT or cancer. Further studies are needed to clarify whether a longer, but definite treatment duration effectively prevents these recurrences.
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Affiliation(s)
- Marco P Donadini
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
- Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
- Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - Samuela Pegoraro
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
- Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - Fulvio Pomero
- Department of Internal Medicine, Ospedale ‘S. Croce e Carle’, Cuneo, Italy
| | - Chiara Brignone
- Department of Internal Medicine, Ospedale ‘S. Croce e Carle’, Cuneo, Italy
| | - Luigina Guasti
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
- Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - Luigi Steidl
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
- Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - Walter Ageno
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
- Azienda Socio-Sanitaria Territoriale dei Sette Laghi, Varese, Italy
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Barco S, Corti M, Trinchero A, Picchi C, Ambaglio C, Konstantinides SV, Dentali F, Barone M. Survival and recurrent venous thromboembolism in patients with first proximal or isolated distal deep vein thrombosis and no pulmonary embolism. J Thromb Haemost 2017; 15:1436-1442. [PMID: 28439954 DOI: 10.1111/jth.13713] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Indexed: 12/11/2022]
Abstract
Essentials The long-term risk of recurrence and death after distal deep vein thrombosis (DVT) is uncertain. We included subjects with first proximal or isolated distal DVT (IDDVT) and no pulmonary embolism. The risk of symptomatic and asymptomatic recurrence is lower after IDDVT (vs. proximal). IDDVT may be associated with a lower long-term risk of death, especially after unprovoked DVT. SUMMARY Background A few studies have focused on the risk of recurrence after first acute isolated distal deep vein thrombosis (IDDVT) compared with proximal DVT (PDVT), whereas the incremental risk of death has never been explored beyond the first 3 years after acute event. Methods Our single-center cohort study included patients with first symptomatic acute PDVT or IDDVT. Patients were excluded if they had concomitant pulmonary embolism (PE) or prior venous thromboembolism. The primary outcomes were symptomatic objectively diagnosed recurrent PDVT or PE and all-cause death. Results In total, 4759 records were screened and 831 subjects included: 202 had symptomatic IDDVT and 629 had PDVT. The median age was 66 years and 50.5% were women. A total of 125 patients had recurrent PDVT or PE during 3175 patient-years of follow-up: 109 events occurred after PDVT (17.3%) and 16 after IDDVT (7.9%). Annual recurrence rates were 4.5% (95% confidence interval [CI], 3.7-5.4%) and 2.0% (95% CI, 1.1-3.2%), respectively, for an adjusted hazard ratio (aHR) for IDDVT patients of 0.32 (95% CI, 0.19-0.55). Death occurred in 263 patients (31.6% [95% CI, 28.6-34.9%]) during 5469 patient-years of follow-up for an overall annual incidence rate of 4.8% (95% CI, 4.2-5.4%). The mortality rate was 33.5% (n = 211) in PDVT patients and 25.7% (n = 52) in IDDVT patients. The long-term hazard of death appeared lower for IDDVT patients (aHR, 0.75 [95% CI, 0.55-1.02]), especially after unprovoked events (aHR, 0.58 [95% CI, 0.26-1.31]). Conclusions Compared with PDVT, IDDVT patients were at a lower risk of recurrent VTE. The risk of death appeared lower after IDDVT during a median follow-up of 7.6 years.
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Affiliation(s)
- S Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University-Mainz, Mainz, Germany
- Department of Internal Medicine, Fondazione IRCCS Policlinico 'San Matteo', Pavia, Italy
| | - M Corti
- Department of Internal Medicine, Fondazione IRCCS Policlinico 'San Matteo', Pavia, Italy
| | - A Trinchero
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University-Mainz, Mainz, Germany
- Department of Internal Medicine, Fondazione IRCCS Policlinico 'San Matteo', Pavia, Italy
| | - C Picchi
- Department of Internal Medicine, Fondazione IRCCS Policlinico 'San Matteo', Pavia, Italy
- Department of Internal Medicine, Presidio Ospedaliero 'Macedonio Melloni', ASST FBF 'Sacco', Milan, Italy
| | - C Ambaglio
- Department of Internal Medicine, Fondazione IRCCS Policlinico 'San Matteo', Pavia, Italy
| | - S V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University-Mainz, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - F Dentali
- Department of Clinical and Experimental Medicine, Ospedale di Circolo, Insubria University, Varese, Italy
| | - M Barone
- Department of Internal Medicine, Fondazione IRCCS Policlinico 'San Matteo', Pavia, Italy
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Abstract
The natural history of isolated distal deep-vein thrombosis (IDDVT) is still uncertain, as well as the real clinical risks associated with the disease and the need for its diagnosis and treatment. While more and more IDDVTs are diagnosed in everyday clinical practice, their appropriate therapeutic management is, unfortunately, far from straightforward, and different recommendations on how patients with diagnosed IDDVT should be treated are present between expert professionals and even among international guidelines. The present article aims at briefly reviewing the issue of IDDVT therapy in general, particularly focusing on the different approaches to the treatment of the disease that have been suggested by recent guidelines, those that are currently adopted in clinical practice, and necessary future directions.
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Affiliation(s)
- Gualtiero Palareti
- Cardiovascular Diseases, University of Bologna, Bologna, Italy.
- Arianna Anticoagulation Foundation, Via Paolo Fabbri 1/3, 40138, Bologna, Italy.
| | - Michelangelo Sartori
- Unit of Angiology and Blood Coagulation, University Hospital of Bologna, Bologna, Italy
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