Testicular vein thrombosis: Incidence of recurrent venous thromboembolism and survival.

PURPOSE: Testicular vein thrombosis (TVT) etiology, recurrence, and survival were compared with lower extremity deep vein thrombosis (DVT) in order to determine whether treatment guidelines for DVT could be applied to TVT. PATIENTS AND METHODS: An inception cohort of patients with confirmed TVT (January 1995-October 2015) was compared to a control group of patients with lower extremity DVT matched by age, gender, and diagnosis date. RESULTS: Thirty-nine men with TVT were identified; 15 (38%) with isolated TVT. Left testicular vein was affected in 77% patients; there were no cases of bilateral TVT. Cancer was over twofold more common in TVT patients (59% vs 28%, P = .01). Most cancers (78%) involved organs in proximity to the testicular vein. Although TVT patients were less frequently treated with anticoagulants (49% vs 97%, P = .0001), recurrence rates were similar to DVT group (TVT 4.2 vs DVT 1.1 per 100 patient-years, P = .11). Despite higher cancer prevalence, survival rates were similar between groups (31% vs 28%; P = .34). Major bleeding events were rare (one patient per group). CONCLUSIONS: Identifying TVT should prompt a search for a regional malignancy. Despite the high cancer prevalence and low utilization of anticoagulants, recurrent venous thrombosis and mortality rates are similar to DVT patients.

Thrombosis of atypical location: how to treat patients in the era of direct oral anticoagulants?

In 4% of cases, venous thromboembolism (VTE) involves organ­related venous territories such as splanchnic, renal, gonadal, and cerebral venous segments, and is often called venous thromboembolism of atypical location (VTE­AL). Recommendations regarding the method, intensity, and duration of anticoagulant therapy for VTE­AL are not well established. Direct oral anticoagulants (DOACs) have been a promising alternative to vitamin K antagonists in the treatment of acute VTE. However, all major clinical trials on DOACs excluded patients with VTE­AL. Therefore, data on the use of DOACs in patients with VTE­AL are still limited to case reports and small clinical series, with a relative predominance of publications on splanchnic vein thrombosis including mesenteric, splenic, portal, and hepatic vein thrombosis. The only randomized clinical trial comparing a clinical outcome of patients with acute portal vein thrombosis randomized to either rivaroxaban or warfarin treatment yielded significantly impaired results due to the use of an atypical rivaroxaban dose. A prospective registration of clinical outcome for DOACs used in patients with VTE­AL, in those with VTE of typical location, and in those with VTE­AL treated with enoxaparin showed similar VTE recurrence and major bleeding rates in all 3 groups. High cancer prevalence, typical for VTE­AL, significantly impacted survival as well as VTE recurrence rates and major bleeding outcomes in this study. In general, although still limited, the results for DOAC use in VTE­AL are encouraging and we do not hesitate to use DOACs, particularly rivaroxaban or apixaban, in selected patients with VTE­AL.

Rivaroxaban and Apixaban for Initial Treatment of Acute Venous Thromboembolism of Atypical Location.

OBJECTIVES: To assess the outcome of direct oral anticoagulants (DOACs), specifically Xa inhibitors: rivaroxaban and apixaban, for the treatment of venous thromboembolism (VTE) of atypical location (VTE-AL), portal, mesenteric, hepatic, splenic, gonadal, renal, and cerebral veins, prospectively collected data of Mayo Thrombophilia Clinic Registry were used. METHODS: Patients with acute VTE-AL treated with DOACs, enrolled between March 1, 2013, and February 1, 2017, were compared with patients with VTE of typical location (VTE-TL: deep vein thrombosis of extremities and/or pulmonary embolism) receiving DOACs and with patients with VTE-AL treated with enoxaparin. RESULTS: Out of 623 patients with acute VTE receiving the study drug within 14 days of diagnosis, there were 63 with VTE-AL: 36 on DOAC, 23 on enoxaparin, and 4 on warfarin; 352 received DOAC for VTE-TL. The VTE-AL treated with DOAC/enoxaparin included the following: splanchnic (26/22), ovarian (8/2), renal (3/5), and cerebral veins (1/1), respectively. Recurrence rate (per 100 person-years) for the VTE-AL group receiving DOAC was 7.3, which was not different when compared with those for VTE-TL (2.4; P=.13) and VTE-AL groups receiving enoxaparin (23.7; P=.37). Major bleeding rate in the VTE-AL group receiving DOAC was not different compared with those for VTE-TL (7.2 vs 3.0; P=.26) and VTE-AL groups on enoxaparin (22.4; P=.31). Mortality was higher in the VTE-AL group on DOAC compared with the VTE-TL group (21.45 [95% CI, 7.87-46.69] vs 8.26 [95% CI, 5.35, 12.20]; P=.03). All patients with VTE-AL with events had cancer. CONCLUSION: The VTE recurrence and bleeding rates for rivaroxaban and apixaban used in VTE-AL are not different from those in patients with VTE-TL and similar to that for enoxaparin.