Venous Thrombosis and Hypercoagulability in the Abdomen and Pelvis: Causes and Imaging Findings.

Venous thromboembolism (VTE), which includes deep venous thrombosis and pulmonary embolism, is a significant cause of morbidity and mortality. In recent decades, US, CT, and MRI have surpassed catheter-based angiography as the imaging examinations of choice for evaluation of vascular structures and identification of thrombus owing to their ready availability, noninvasive nature, and, in the cases of US and MRI, lack of exposure to ionizing radiation. As a result, VTE and associated complications are commonly identified in day-to-day radiologic practice across a variety of clinical settings. A wide range of hereditary and acquired conditions can increase the risk for development of venous thrombosis, and many patients with these conditions may undergo imaging for unrelated reasons, leading to the incidental detection of VTE or one of the associated complications. Although the development of VTE may be an isolated occurrence, the imaging findings, in conjunction with the clinical history and vascular risk factors, may indicate a predisposing condition or underlying diagnosis. Furthermore, awareness of the many clinical conditions that result in an increased risk of venous thrombosis may aid in detection of thrombus and any concomitant complications. For these reasons, it is important that practicing radiologists be familiar with the multimodality imaging findings of thrombosis, understand the spectrum of diseases that contribute to the development of thrombosis, and recognize the potential complications of hypercoagulable states and venous thrombosis. Online DICOM image stacks and supplemental material are available for this article. ©RSNA, 2020.

The role of anticoagulation in pylephlebitis: a retrospective examination of characteristics and outcomes.

Pylephlebitis, or suppurative thrombophlebitis of the portal vein, typically occurs in the context of an intraabdominal infection or abdominal sepsis. Antibiotics are the mainstay of treatment. The role of anticoagulation in the management of pylephlebitis is controversial, and data regarding its impact on outcomes is limited. The records of 67 consecutive patients with pylephlebitis treated at our institution over a 19 year period were retrospectively reviewed. Data was gathered regarding their baseline characteristics, presentations, management, and outcomes. Patients who did and did not receive anticoagulation were compared. Outcomes of interest included survival, portal vein thrombosis (PVT) resolution, development of chronic symptomatic portal hypertension, and major bleeding. Forty-seven patients received anticoagulation and 20 did not. The anticoagulated and non-anticoagulated groups did not differ significantly with respect to potential covariates or confounders. Anticoagulated patients had significantly higher rates of PVT resolution than non-anticoagulated patients (58% vs. 21%, p = 0.0201). This translated to lower rates of future chronic portal hypertensive symptoms among anticoagulated patients (11% vs. 47%, p = 0.0034). Anticoagulated patients had a trend toward improved survival however this improvement was not significant on multivariable analysis. There was no significant difference in rates of major bleeding between groups. Thrombophilia testing was common in this cohort however the occurrence of meaningful positive results was exceedingly low. Anticoagulation significantly improves the rate of PVT resolution, and significantly reduces the rate of chronic symptomatic portal hypertension, among patients with pylephlebitis. Treatment of pylephlebitis should incorporate the use of systemic anticoagulation whenever possible.

Assessment of hypercoagulability using thromboelastography predicts advanced status in renal cell carcinoma.

BACKGROUND: Thromboelastography (TEG) has been established as a sensitive method to assess the whole coagulation process. The aim of the study was to evaluate the diagnosis significance of TEG on hypercoagulability in patients suffering renal mass. METHODS: A total of 478 patients were diagnosed with renal tumor by histolopathologic examination and were assigned to three groups. Group A: 79 patients with benign renal tumor; Group B: 317 patients with renal cell carcinoma (RCC, Fuhrman grades I and II); Group C: 82 patients with high-risk RCC (Fuhrman grades III and IV). Subgroup analysis was performed in malignant renal tumor patients according to the TMN classification. The clinical data, whole blood TEG, and conventional coagulation tests were reviewed. RESULTS: There was no statistically significant difference between subgroups in respect to conventional coagulation tests. Hypercoagulablity was marked in Group C according to the TEG parameters. The elevated platelets and fibrinogen is linked with hypercoagulability in renal tumor. The positive correlation was between fibrinogen and MA value (r = .663, P < .05). The pathologic tumor stages were also associated with the TEG parameters. CONCLUSION: Patients suffering advanced RCC are hypercoagulable which can be identified by TEG. MA value could be potential diagnosis indicators for detecting high-grade RCC.

Uterine Radial Artery Resistance Index Predicts Reproductive Outcome in Women with Recurrent Pregnancy Losses and Thrombophilia.

Uterine radial artery resistance index (URa-RI) by Doppler ultrasound may reflect the changes in the uteroplacental circulation and be associated with adverse events in early pregnancy. Recurrent pregnancy losses (RPL) are associated with thrombophilia, and anticoagulation treatment with low molecular weight heparin improves pregnancy outcome in women with RPL and thrombophilia. A retrospective cohort study was conducted in 139 pregnant women with 3 or more RPL and thrombophilia. The relationship between pregnancy outcome and dynamic changes of URa-RI was analyzed in 116 women who delivered a liveborn infant and 23 who miscarried the index pregnancy. Patients were on preconception low molecular weight heparin, low-dose aspirin (81mg per day), and prednisone treatment. URa-RI was measured during periovulation time, at the time of positive pregnancy test, and then repeated every two weeks until 32-week gestation or the time of miscarriage. The URa-RI at 8-week gestation was significantly higher in women who miscarried the index pregnancy than those who delivered alive born infant (0.51±0.08 vs. 0.42±0.03, P<0.001). Receiver operating characteristic curve analysis demonstrated that URa-RI of 8 wk gestation effectively distinguished women who miscarried from those who had a live birth with an area under the curve of 82.6% (95% CI 69.01-97.17). After adjusting for covariates including age, BMI, and number of miscarriages, multiple logistic regression models showed that each 0.1 unit increase of URa-RI of 8 wk gestation was associated with 18.70-point increase in the risk of miscarriage (OR19.70, 95%CI 4.26-91.1, P<0.001), and women with an URa-RI≥0.45 had an OR of 49.48 (95% CI 8.01-307.95; P<0.001) for miscarriage compared to those who had URa-RI<0.45. In women with RPL and inherited thrombophilia, increased URa-RI at 8-week gestation was associated with spontaneous abortion independent of other risk factors while they were on anticoagulation treatment.

Acute pulmonary thromboembolism caused by factor V Leiden mutation in South Korea: A case report.

RATIONALE: Although Factor V Leiden (FVL) mutation is a major cause of inherited thrombophilia in Western populations; the mutation is extremely rare in Asia. PATIENT CONCERNS: Here we report a case of a 28-year old Korean woman admitted to our hospital with extensive pulmonary embolism. DIAGNOSIS: She was heterozygous for FVL mutation up on evaluation, and screening for asymptomatic family members also revealed heterozygous FVL mutation for her mother. INTERVENTIONS: Enoxaparin 1 mg/kg was initiated, followed by rivaroxaban 15 mg every 12 hours. OUTCOMES: The patient showed improvement in both subjective dyspnea and right ventricular dysfunction and was successfully discharged after five hospital days. LESSONS: FVL mutation screening may be considered in Asian patients with thrombophilia of uncertain etiology in the future.

Secondary Omental Infarction in a Patient with a Hypercoagulable State.

Omental infarction is a rare cause of acute and non-specific abdominal pain. We report a case of a 46-year-old man who presented to the emergency room with right upper quadrant cramping pain that was of sudden onset. The patient's presentation was later diagnosed as an omental infarction, by an abdominal CT. After extensive work-up, it was revealed that the cause of the patient's omental infarction was secondary to a hypercoagulable state caused by antiphospholipid syndrome, based on his thrombophilia work-up. The patient was successfully managed conservatively and was started on lifelong anticoagulation. The patient was followed up with an abdominal CT after 2 months into therapy, which showed a decrease in the size of the omental infarction and a significant improvement in his state.

Hypercoagulability after distal pancreatectomy: Just meaningless alterations?

BACKGROUND: Perioperative and short-term postoperative parameters are similar comparing spleen-preserving distal pancreatectomy (SPDP) and distal pancreatectomy with splenectomy (DPS). But there are no sound data evaluating the long term risk of postoperative thromboses and infectious complications after splenectomy. The present study evaluated whether the coagulation status differs in patients after SPDP and DPS, and whether that matters clinically. METHODS: A total of 41 patients after DP (SPDP = 20; DPS = 21) were followed up, focusing on alterations of patient coagulation and immune status. To assess kinetics of the coagulation process, qualitative tests (multiple platelet function analyzer, rotational thrombelastography) were used in addition to global coagulation tests. RESULTS: Coagulation tests revealed a significant enhanced tendency for blood-platelet aggregation and coagulation activation in patients after DPS compared to patients after SPDP. No septic or thromboembolic events were observed in any patient. CONCLUSION: Hypercoagulability in splenectomized patients persists over years. Thus, a correlation of this finding with thromboembolic events and mortality years after splenectomy should to be performed in a large cohort.

A genetic risk factor for thrombophilia in a Han Chinese family.

Thrombophilia is a multifactorial disorder involving environmental and genetic factors. Well­known factors that result in predisposition to congenital disorders associated with thrombophilia include antithrombin deficiency, protein C and S deficiency, Factor V Leiden mutation, abnormal prothrombin and antiphospholipid syndrome. The present study revealed an association between a mutation of the F2 gene, which codes for coagulation factor II, thrombin, and the risk of thrombophilia in a Han Chinese family, of which four members (I­2, II­2, II­3 and III­1) had a history of deep venous thromboembolism. The disease was measured in this family using laboratory measurements and computed tomography angiography. To identify the abnormality underlying the increased thrombophilia risk, whole­exome sequencing technology was used to analyze two affected individuals (II­2 and III­1). An exonic missense F2 mutation, T165M (NM_000506:c.C494T:p.T165M;rs5896), was identified from a total of 2,222 and 2,203 genetic variations observed in the two affected individuals, respectively, which were subsequently filtered and confirmed using Sanger sequencing. I­2, II­3 and III­1 shared this mutation with the proband (II­2), and II­6 had a heterozygous form of the mutation. This deleterious mutation was not identified in normal controls. The present study may improve understanding of the function of the F2 gene.

A case of hereditary thrombophilia in a Chinese Han patient with both antithrombin deficiency and Factor V Leiden: A case report and literature review.

Hereditary thrombophilia is a blood coagulation disorder that increases the risk of venous thromboembolism, due to several genetic risk factors. Factor V Leiden(FVL) is the most common contributing factor to thrombophilia in the Caucasian population but very rare in Asian population and concurrent occurrence of antithrombin(AT) deficiency and FVL in Chinese Han population is even more rare. We report the case of a 22-year-old female who experienced recurrent intracranial venous thromboses, furthermore, color Doppler ultrasound showed multiple extracranial thromboses. Thrombophilia was suspected and screening tests indicated decreased AT activity and activated protein C sensitivity ratio, then further sequencing analysis identified missense mutations in SERPINC1 and F5. The patient's condition slightly improved after treatment with low molecular heparin during hospitalization followed by oral warfarin after discharge. The present report highlights a very rare case of thrombophilia with concurrent occurrence of AT deficiency and FVL in a Chinese Han patient, and our findings suggest that genetic testing is a reliable approach for identifying different risk factors.

[Testing for thrombophilia in patients with venous thromboembolism - why and whom to test?] / Thrombophilie-Diagnostik bei venöser Thromboembolie ­ wann ist sie sinnvoll?

Hereditary and acquired thrombophilias are known risk factors for a first venous thromboembolism (VTE). In contrast, the relative risk of VTE recurrence in presence of hereditary thrombophilia seems to be at most moderately elevated. However, thrombophilia still contributes to a greater extent to the absolute risk of VTE recurrence. This is explained by the 20-50-fold increased risk of VTE in a subject after a first VTE when compared to the state without previous VTE. Testing for thrombophilia may therefore be helpful in patients at intermediate risk of recurrence in whom the finding of a "strong" thrombophilia can bring about a decision for long-term anticoagulation.

Congenital limb deficiencies with vascular etiology: Possible association with maternal thrombophilia.

Congenital limb deficiency defects (LDDs) are etiologically heterogeneous. Acquired causes include amniotic bands, teratogens exposure, and chorionic villus sampling before 10 weeks' gestation and intrinsic causes include single-gene disorders and chromosome abnormalities. However, a substantial number of cases, especially terminal transverse deficiency defects, occur without an obvious cause and are ascribed to vascular disruption events. Some studies have found an association between maternal thrombophilia and congenital LDDs. We investigated this association through a review of all prenatally identified LDDs at a major tertiary care center in Toronto, Canada over a 12-year period. Our results showed a higher prevalence of thrombophilias among women with a pregnancy affected with an LDD when compared to the general population [χ2 (3) = 54.63, P < 0.01]. Our research was strengthened by the inclusion of affected pregnancies regardless of outcome, and strict criteria to avoid including LDDs with a non-vascular etiology. Most LDDs were identified during the routine 18-20 week anatomy ultrasound, but some were discovered as early as 13 weeks' gestation. We found an excess of left-sided defects among terminal transverse but not longitudinal deficiencies; additionally, all diagnoses of maternal thrombophilia occurred in the terminal transverse group. Our results support thrombophilia screening in all women with a prenatally diagnosed fetal LDD as well as careful evaluation of the fetal extremities during prenatal ultrasounds in women with a known thrombophilia. © 2016 Wiley Periodicals, Inc.

Poor Outcome of Stroke Patients With Atrial Fibrillation in the Presence of Coexisting Spontaneous Echo Contrast.

BACKGROUND AND PURPOSE: Spontaneous echo contrast (SEC) is frequently detected in patients with atrial fibrillation (AF). Coexisting SEC in patients with AF may be associated with heightened thrombogenicity, which affects stroke outcomes. METHODS: Consecutive stroke patients with nonvalvular AF who underwent transesophageal echocardiography were included in this study. We compared initial stroke severity and functional outcome at 3 months between the patients with and those without SEC. RESULTS: Of 440 patients with nonvalvular AF who underwent transesophageal echocardiography during a 7-year period, 193 (43.9%) patients had SEC. Stroke was more severe in the patients with SEC than in those without SEC (National Institute of Health Stroke Scale score: median [interquartile range], 5 [2-12] versus 3 [1-8]; P=0.004). The patients with SEC more frequently had poor functional outcomes (modified Rankin scale score of >2) at 3 months than those without SEC (32.3% versus 16.1%; P<0.001). On multivariate analysis, the presence of SEC was an independent factor of poor outcome (odds ratio, 2.09; 95% confidence interval, 1.24-3.53). CONCLUSIONS: In the ischemic stroke patients with nonvalvular AF, coexisting SEC was associated with more severe stroke and was predictive of poor long-term functional outcome.

Prevalence of asymptomatic lower limb venous thrombosis in infertile women with thrombophilic disorders.

OBJECTIVE: We sought to assess the prevalence of asymptomatic venous thrombosis in infertile women with thrombophilic disorders (TDs). METHODS AND RESULTS: A total of 73 infertile women with TDs underwent duplex ultrasound scan to evaluate superficial and deep venous circulation of lower limbs. A control group of 35 infertile women without TDs was included. A single TD was found in 13 (17.8%) subjects, and 40 (54.8%) women presented a combined defect (more than three alterations). No residual mural thrombosis (RT) was noted in any deep veins. We found RT in 48 (65.8%) patients of TD group, while no RT was found in the control group (p < 0.0001). None of the clinical and prothrombotic factors were predictors of RT (all p > 0.20), and frequency of TD did not correlate with multi-vessel RT (p = 0.252). CONCLUSIONS: No signs of deep vein thrombosis but high prevalence of superficial RT is present in infertile women with TDs. Further studies are needed to assess the prognostic value of our findings.