Treatment modalities to manage hepatocellular carcinoma patients with portal vein thrombosis: a systematic review and meta-analysis.

BACKGROUND: A number of therapeutic treatment strategies exist for patients with hepatocellular carcinoma (HCC) and portal vein thrombosis (PVT). The aim of this review is to provide a current understanding of treatment options and determine the relative effectiveness of treatment options in preventing mortality over 24 months. METHODS: A search was conducted in PubMed, EMBASE and Cochrane CENTRAL from 2007 to 2022. Articles were screened to identify those that reported on all-cause mortality among treated, non-palliative patients with HCC and PVT. Study quality was assessed using the Cochrane Risk of Bias in Non-Randomized Studies of Interventions tool (ROBINS-1). Mortality rates at prespecified timepoints between 6 and 24 months were extracted and summarized using a random-effects DerSimonian-Laird model. This review was registered a priori on PROSPERO (CRD42022290708). RESULTS: When comparing radiotherapy (RT) to sorafenib and combined transarterial chemoembolization (TACE), there was a trend that RT yields better survival at 6 months [odds ratio (OR) 0.70, 95% confidence interval (CI): 0.28-1.76]. When comparing sorafenib to Y90 and RT, sorafenib was associated with higher odds for mortality at 6 months (OR 2.20, 95% CI: 1.11-4.39). No significant differences were noticed from 12 to 24 months. CONCLUSIONS: Future strategies for HCC with PVT should look at the combination of radiation and systemic treatments either concurrently or sequentially.

Rehabilitation in the Setting of Untreated Cancer-Associated Acute Deep Vein Thrombosis.

OBJECTIVE: Research is needed to guide the timing and safety of rehabilitation (physical and occupational therapy) in patients with acute deep venous thrombosis (DVT) that is untreated due to contraindications. CASE DESCRIPTION: A 21-year-old man with Hodgkin lymphoma was admitted to the hospital for neutropenic fever. He developed gastrointestinal bleeding, diffuse alveolar hemorrhage, and bilateral lower-extremity DVT. He was not a candidate for chemical anticoagulation or placement of an inferior vena cava filter owing to thrombocytopenia. Rehabilitation was initially deferred because of concern that the thrombus could travel to the lungs, causing a pulmonary embolism. Rehabilitation was, however, started 4 days after the initial diagnosis of lower-extremity DVT to assess functional mobility and activities of daily living skills to prepare for discharge from the hospital. RESULTS: The patient experienced no bleeding events during rehabilitation, and his acute, untreated DVT did not propagate based on clinical assessment. His Activity Measure for Post-Acute Care (AM-PAC) "6 Clicks" Basic Mobility score improved from 30.25 to 35.55 over the period of 11 days while he received rehabilitation. CONCLUSION: Despite having an acute bilateral lower-extremity DVT that was untreatable owing to thrombocytopenia, the patient successfully participated in rehabilitation and improved his physical functional status without an adverse event. Untreated acute venous thromboembolism in the setting of recent history of major bleeding raise concerns about physical activity restrictions. It is critical to consider both the risks and benefits of mobilizing patients and prescribing exercises in patients with these conditions.

Management of hepatocellular carcinoma patients with portal vein tumor thrombosis: A narrative review.

BACKGROUND: Hepatocellular carcinoma (HCC) is one of the main reasons for malignancy-related death. Portal vein tumor thrombosis (PVTT) is the most common form of macrovascular invasion related to HCC occurring in 10%-60% of patients. HCC with PVTT is usually characterized by worsening liver function, vulnerability to blood metastasis, higher incidence of complications associated with portal hypertension, and intolerance to treatment when compared with that without PVTT. If only treated with supportive care, the median survival of HCC with PVTT is about 2.7 months. In the past, sorafenib was the only recommended therapy by guidelines with limited effectiveness. This narrative review aimed to describe the current management options for HCC with PVTT. DATA SOURCES: We have reviewed literature from PubMed on the treatment of HCC with PVTT and compiled evidence-based facts on effective therapies available for different types of PVTT. RESULTS: Sorafenib monotherapy is not much effective, but combining it with other methods can improve survival. Each type of PVTT can benefit from the combination of transarterial chemoembolization and sorafenib than sorafenib monotherapy. The tumor downstaging can be realized possibly after transarterial chemoembolization, but tumor invasion into the main trunk of the portal vein greatly impairs efficacy. Although surgery is a curative approach, it is often not recommended for Vp4 PVTT. Some new methods can broaden the indication, but further explorations are needed. Radiotherapy can decrease the possibility of Vp3 progression to Vp4, but building a forecast model of best radiation dose and response is necessary. Systemic chemotherapy, hepatic arterial infusion chemotherapy, radiofrequency ablation, portal stenting, and traditional Chinese medicine are also beneficial in Vp3-4 PVTT. The accurate diagnosis of PVTT can be made by radiomics, and prognostic classification models can be used to design personalized treatments. The application of new treatment methods such as the atezolizumab plus bevacizumab scheme may increase survival. CONCLUSIONS: HCC with PVTT is still a thorny problem, and effective therapeutics need to be explored.

The therapeutic efficacy and safety of traditional Chinese medicine injection combined with low-molecular-weight heparin on the acute lower extremity deep venous thrombosis: A protocol for systematic review and network meta-analysis.

BACKGROUND: Lower extremity deep venous thrombosis (LEDVT) of lower extremities is one of the common clinical diseases. Lack of a timely treatment in the acute stage easily causes pulmonary embolism, thus seriously threatening patients' life. Low-molecular-weight heparin (LMWH), as a new generation of heparin-based anticoagulant and antithrombotic drug, is now commonly used in the clinical treatment of acute lower extremity deep venous thrombosis (ALEDVT). Relevant randomized controlled trials (RCTs) have reported the therapeutic efficacy and safety of Traditional Chinese medicine injection (TCMJ) combined with LMWH on ALDVT, although their conclusions remain controversial. In addition, the efficacy of various TCMJs has rarely been analyzed and compared. This study aims to evaluate the therapeutic efficacy and safety of TCMJ combined with LMWH on ALEDVT through a network meta-analysis. METHODS: RCTs reporting TCMJ combined with LMWH and LMWH along for the treatment of ALEDVT published before November 2021 will be searched in online databases, including the Cochrane Library, Embase, PubMed, Web of Science, Wanfang, Chongqing VIP Chinese Science and Technology Periodical Database, Chinese Biomedical Literature Database, and Chinese National Knowledge Infrastructure. Two investigators will be independently responsible for literature screening, data extraction, and quality evaluation according to Cochrane's risk of bias assessment tool. R software will be used to perform a network Meta-analysis. RESULTS: The results of this meta-analysis will be submitted to a peer-reviewed journal for publication. CONCLUSION: This study will provide high-quality, evidence-based medical evidence for comparing the therapeutic efficacy and safety of TCMJ combined with LMWH and LMWH alone on ALEDVT.

Anlotinib followed by transarterial chemoembolization and radiofrequency ablation is a safe and effective initial treatment for hepatocellular carcinoma patients with portal vein tumor thrombus: A retrospective case series study.

BACKGROUND: Portal vein tumor thrombus (PVTT) remains a poor prognostic factor occurring in about 10%-40% of patients with hepatocellular carcinoma (HCC) for the optimal treatment is controversial. Anlotinib is an novel small molecule inhibitor that has a broad spectrum of inhibitory activities on tumor angiogenesis and growth. However, so far, no studies have reported the use of anlotinib in the treatment of HCC patients with PVTT. Here, we evaluated the safety and efficacy of anlotinib, followed by transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) for the treatment of patients with HCC and PVTT. MATERIALS AND METHODS: A total of 145 consecutive HCC patients who underwent TACE in combination with RFA were enrolled in the retrospective study. Twenty-eight patients were diagnosed with PVTT and received anlotinib as basic treatment. The adverse events (AEs) were graded according to the National Cancer Institute Common Terminology Criteria for AEs Version 4.0. Time to tumor progression (TTP) and overall survival (OS) were calculated using the Kaplan-Meier method. RESULTS: The most common toxicities related to anlotinib were pharyngalgia (53.6%), fatigue (42.9%), and hand-foot skin reaction (39.3%). The median OS was 13 months (range: 3-18 months) with 1-year OS rate of 64.3%. The median TTP was 7 months (range: 1-12 months) with 6-month rate of 46.4%. CONCLUSION: Anlotinib followed by TACE and RFA is a safe and effective initial treatment modality for HCC patients with PVTT. Anlotinib may be a promising therapeutic option for relieving and/or stabilizing HCC with PVTT.

Ten-year trends in iliofemoral deep vein thrombosis treatment and referral pathways.

OBJECTIVES: Iliofemoral deep venous thrombosis is associated with an increased risk of developing post-thrombotic syndrome resulting in reduced quality of life. As there is debate about best management practices, this study aimed to examine the referral and treatment pathways for patients presenting with iliofemoral deep venous thrombosis over an 11-year period at our institution. METHODS: We conducted a retrospective review of patients diagnosed with lower limb deep vein thrombosis between 2010 and 2020. Ultrasound report findings were reviewed for the presence of iliofemoral deep venous thrombosis with acute, occlusive, or proximal clot. Multiple factors were extracted, including patient demographics, risk factors, diagnostic methods, interventions, referrals, and details of follow-up. The CaVenT and ATTRACT trials studied the benefit of thrombolysis in the early phase of iliofemoral deep venous thrombosis management as compared to anticoagulation alone. An analysis was conducted of patients requiring thrombolysis to determine whether these trials impacted physician practice patterns for thrombolysis. Data were organized and examined by year for trends in treatment and referral pathways. RESULTS: The review yielded 2792 patients assessed for lower limb deep venous thrombosis by ultrasound. Four hundred and sixty-seven (16.7%) patients were confirmed to have an occlusive iliofemoral deep venous thrombosis. The average age was 62.7 years (18-101 years). Half (50.4%) of the patients were male. The most common etiology for clot was malignancy-induced hypercoagulable state (39.0%). There was no difference in incidence of iliofemoral deep venous thrombosis diagnosed by ultrasound per year, with an average of 42.5 per year and a peak of 61. There was a trend towards increased rates of computed tomography imaging, ranging between 9.1% and 52.9%. The rate thrombolysis per year ranged between 1.8% and 8.9%, with a range of 4.3% (n = 20) to 8.9% (n = 5) in 2018. The use of pharmacomechanical thrombolysis increased, from 25% (n = 1) in 2010-2012 to 87.5% (n = 7) in 2018-2020. The rate of inferior vena cava filter insertion alone decreased from 18.2% in 2010 (n = 4) to 5.9% (n = 1) in 2020. The length of thrombolysis treatment also decreased, from 100% of patients (n = 4) receiving treatment duration greater than 24 h in 2010-2012 to 0% (n = 0) in 2018-2020. About 45% of patients receiving thrombolysis (n = 9) had venous stenting. No difference in treatment outcomes were observed, with greater than 87.5% of patients reaching intermediate to full resolution of clot burden. No patients experienced intracranial hemorrhage. CONCLUSIONS: The results of this analysis highlight the change in practice in our institution over time. The low rate of intervention likely reflects the current lack of consensus in published guidelines. It is important for future work to elicit the most appropriate management pathways for patients with iliofemoral deep venous thrombosis.

INTRABEAM intraoperative radiotherapy combined with portal vein infusion chemotherapy for treating hepatocellular carcinoma with portal vein tumor thrombus.

BACKGROUND: Portal vein tumor thrombus (PVTT) is common in hepatocellular carcinoma (HCC). Recent studies indicate that more aggressive treatments, including surgical resection or locoregional treatment, may benefit selected HCC patients with PVTT. External radiation therapy and infusion chemotherapy were found to achieve good outcomes; however, the use of low-energy x-ray radiation system (INTRABEAM), intraoperative radiation therapy, and portal vein infusion chemotherapy for PVTT has not been reported. We present a case of HCC with PVTT. The patient underwent hemihepatectomy and thrombectomy along with intraoperative radiotherapy (IORT) using a portable INTRABEAM radiation system. Subsequently, to treat PVTT, portal vein infusion chemotherapy with FOLFOX (leucovorin [Folinic acid], fluorouracil, and oxaliplatin) regimen was administered. There were no obvious post-operative complications. After 20 months follow-up period, no obvious tumor recurrence had been observed, and PVTT gradually disappeared completely. CONCLUSIONS: IORT using the INTRABEAM radiation system combined with portal vein infusion chemotherapy is promising for select patients with PVTT.

Hyperhomocysteinemia Causes Severe Intraoperative Thrombotic Tendency in Superficial Temporal Artery-middle Cerebral Artery Bypass.

CASE: Two years ago, annual magnetic resonance imaging for unruptured right internal carotid artery aneurysm of a 47-year-old woman detected a cerebral infarct in her right occipital lobe which was unknown etiology and antiplatelet therapy was initiated. She presented with sensory disorder of her left fingers 4 months ago. Infarction in right parieto-occipital cortex and severe stenosis of right middle cerebral artery was revealed. Her laboratory test was normal except remarkably high homocysteine value. Regardless of dual anti-platelet therapy, she suffered from repeated minor stroke and the stenosis was progressing. Therefore, right superficial temporal artery - middle cerebral artery bypass was undertaken. Aspirin and clopidogrel were withdrawn 1 week before the surgery. Two branches were anastomosed with 2 separate frontal M4 branches. Although patency was confirmed immediately after the anastomosis, thrombus formation was revealed after 10 minutes. We needed to perform removal of the thrombus and re-anastomosis twice. Intraoperative administration of aspirin and ozagrel alleviated thrombotic tendency. After surgery, antiplatelet therapy and supplementation with folate and vitamin B were performed. Her postoperative course was uneventful and patency of both anastomoses was confirmed. DISCUSSION: Controversy still exists regarding preoperative antiplatelet therapy before superficial temporal artery-middle cerebral artery bypass, and folates and B6-12 vitamins supplementation for hyperhomocysteinemia. Considering intraoperative thrombo tendency in our case, it is recommended to evaluate the homocysteine level before bypass surgery for intracranial stenosis especially for young patients or patients with unknown etiology. Before bypass surgery of the patient with hyperhomocysteinemia, continuation of perioperative antiplatelet drugs and supplementation with folates and B6-12 vitamins are mandatory.

Special Conditions in Venous Thrombembolism - Case Series.

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a preventable cause of in-hospital death, and one of the most prevalent vascular diseases. There is a lack of knowledge with regards to contemporary presentation, management, and outcomes of patients with VTE. Many clinically important subgroups (including the elderly, those with recent bleeding, renal insufficiency, disseminated malignancy or pregnant patients) have been under-represented in randomized clinical trials. We still need information from real life data (as example RIETE). The paper presents case series with VTE in special conditions, including cancer associated thrombosis, malignant homeopathies, as well in high risk population.

Comparative outcomes of catheter-directed thrombolysis plus rivaroxaban vs rivaroxaban alone in patients with acute iliofemoral deep vein thrombosis.

BACKGROUND: Since novel oral anticoagulants (NOACs) have been introduced in the past decade, the first option of deep vein thrombosis (DVT) treatment is toward NOACs. However, aggressive and early thrombus removal strategy is widely used for treating acute iliofemoral DVT. Consequently, optimal treatment duration, efficacy, and safety of rivaroxaban alone or in combination with catheter-directed intrathrombus thrombolysis (CDT) in acute iliofemoral DVT patients should be investigated. METHODS: Patients with recent acute iliofemoral DVT treated with combined CDT-rivaroxaban (CDT) or rivaroxaban alone (control) were followed for mean (standard deviation) of 25.7 (2.5) months. DVT evolution, treatment efficacy and safety, and predisposing factors for patency and postthrombotic syndrome (PTS) development were analyzed through duplex ultrasonography, plethysmography, venography, and computed tomographic venography. RESULTS: 43.2%, 64.9%, 75.7%, and 72.2% of the CDT patients showed complete patency at 3, 6, 12, and 24 months of treatment compared with the control patients having 8.5%, 36.2%, 55.3%, and 57.4% of cumulative patency at 3, 6, 12, and 24 months, respectively (p = 0.001, 0.017, 0.088, and 0.081, respectively). The p value of the log-rank test comparing patency rates of the two groups was 0.009. The median (interquartile range, IQR) Villalta scores at 24 months were 3 (2-5) and 6 (4-8) in CDT and control patients, respectively (p = 0·001). PTS and bleeding events during therapy were, respectively, found in 35.1% and 63.8% (p = 0.017) and in 27% and 17% of CDT and control patients (p = 0.4). The Kaplan-Meier curve analysis of cumulative patency at 24 months for 6 months of rivaroxaban treatment was significant (p = 0.016). CONCLUSION: Treatment therapy and treatment duration with rivaroxaban alone or in combination with CDT are potentially associated with vein patency at 24 months, and a 6-month lysis rate and obstructive vein can influence PTS development. A larger randomized trial is warranted to confirm these findings.

Jiedu Granule Combined with Transcatheter Arterial Chemoembolization and Gamma Knife Radiosurgery in Treating Hepatocellular Carcinoma with Portal Vein Tumor Thrombus.

BACKGROUND: The potential advantages of Jiedu granule (a compound Chinese herbal medicine) combined therapeutic strategies compared with non-Jiedu granule therapeutic strategies for hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) remain unclear. Thus, the purpose of the study was to investigate the safety and efficacy of Jiedu granule for HCC with PVTT. METHODS: We retrospectively reviewed the clinical data of 190 patients (94 for non-Jiedu and 96 for Jiedu) with HCC and PVTT from March 2012 to October 2016. Patients were followed up by outpatient examination and telephone till November 2018. RESULTS: It was statistically insignificant between the two groups in baseline characteristics. Procedure-related adverse events (AEs) were observed and compared and most of them were not serious which were easily controlled or subsided naturally. No AE-induced death happened. The median overall survival (OS) rates in the single TACE plus GKR and Jiedu granule combined group were 11.3 months (95% CI: 9.168-13.435) and 15.8 months (95% CI: 13.244-18.339), respectively (p = 0.00047). CONCLUSIONS: Jiedu granule combined with TACE plus GKR is safe in HCC patients with PVTT and this Chinese herbal medicine is worthy to be promoted because of better prognosis which needs further research.

Comprehensive treatments for hepatocellular carcinoma with portal vein tumor thrombosis.

Portal vein tumor thrombosis (PVTT) is one of the most common complications in hepatocellular carcinoma (HCC). HCC with PVTT usually indicates poor prognosis, which has a number of characteristics including a rapidly progressive disease course, worse liver function, complications connected with portal hypertension, and poorer tolerance to treatment. The exact mechanisms of PVTT remain unknown, even though some concerned signal transduction or molecular pathways have been identified. In western countries, sorafenib is the only recommended therapeutic strategy regardless of PVTT types. However, multiple treatment options including transhepatic arterial chemoembolization, hepatectomy, radiotherapy, and sorafenib available in the clinic. In this review, we enumerate and discuss therapeutics against patients with HCC having PVTT available in the clinic and put forward directions for future research.

Severe Leg Pain Following Spinal Cord Stimulator Implantation - A Case Report.

Following spinal cord stimulator (SCS) implantation, postoperative pain is commonly incisional or neuropathic from neurological damage. Occasionally, this new pain may mimic symptoms caused by preexisting pathology. This article presents a case of immediate, severe, postoperative leg pain secondary to a lower extremity deep vein thrombosis (DVT) and subsequent pulmonary embolism after percutaneous SCS implantation for failed back syndrome. The risk factors of DVT after spine surgery and perioperative prophylaxis are further discussed with a brief literature review. LEVEL OF EVIDENCE: V.

Multicenter Implementation of a Novel Management Protocol Increases the Outpatient Treatment of Pulmonary Embolism and Deep Vein Thrombosis.

OBJECTIVE: The objective was to determine whether a protocol combining risk stratification, treatment with the direct-acting oral anticoagulant rivaroxaban, and defined follow-up is associated with a greater proportion of patients with venous thromboembolism (VTE) treated as outpatients, without hospital admission. METHODS: We performed a multicenter study of patients diagnosed with VTE (pulmonary embolism [PE] or deep vein thrombosis [DVT]) in two urban EDs, 18 months before and 18 months after implementation of an outpatient VTE treatment protocol. Patients with radiographically confirmed acute VTE were eligible. Our primary outcome was the proportion of VTE patients discharged from the ED or observation unit (i.e., without hospital admission). We performed subgroup analyses according to hospital, DVT and PE, and low-risk PE. We also assessed 7- and 30-day mortality, major bleeding, and returns to the ED. We compared proportions using chi-square and Fisher's exact tests. RESULTS: We enrolled 2,212 patients, 1,081 (49%) before protocol and 1,131 (51%) after protocol. Mean age (59 years vs. 60 years), female sex (49% vs. 49%), other demographics, comorbid illness, and PE risk stratification were similar before and after. After protocol, more VTE (35% from 26%, p < 0.001), PE (18% from 12%, p = 0.002), low-risk PE (28% from 18%, p < 0.001), and DVT (60% from 49%, p = 0.002) patients were treated as outpatients. Mortality, bleeding, and returns to ED were rare and did not increase after protocol. CONCLUSIONS: A treatment protocol combining risk-stratification, rivaroxaban treatment and defined follow-up is associated with an increase in PE and DVT patients treated as outpatients, with no increase in adverse outcomes.

Análise do grau de recanalização da trombose venosa profunda: estudo comparativo de pacientes tratados com varfarina versus rivaroxabana / Analysis of recanalization of deep venous thrombosis: a comparative study of patients treated with warfarin vs. rivaroxaban

Contexto A trombose venosa profunda (TVP) afeta anualmente cerca de dez milhões de pessoas no mundo e tem como principais complicações a embolia pulmonar e a síndrome pós-trombótica. O tratamento padrão é a anticoagulação, que pode ser realizada com heparinas, antagonistas da vitamina K, fondaparinux ou, mais recentemente, com anticoagulantes orais diretos (direct oral anticoagulants, DOACs). Os anticoagulantes diminuem a progressão do trombo e facilitam os mecanismos trombolíticos naturais, fato conhecido como recanalização, que pode ocorrer em graus e tempos variados, influenciados por diversos fatores, dentre eles o tipo de anticoagulação utilizado. Objetivos Avaliar o grau e o tempo de recanalização através da análise de laudos de eco-Doppler colorido (EDC) de pacientes com TVP tratados com DOACs ou com heparina + varfarina. Métodos Foram avaliados retrospectivamente os dados demográficos e os laudos dos EDC dos pacientes com TVP, tratados entre janeiro de 2009 a dezembro de 2016. Os pacientes foram divididos em dois grupos, de acordo com a terapêutica utilizada: Grupo I (heparina + varfarina): 26 pacientes; Grupo II (rivaroxabana): 51 pacientes. Os principais itens observados foram o grau e o tempo para a recanalização. Resultados Foram observadas taxas de recanalização aos 30, 90 e 180 dias de 10%, 52,5% e 78,9%, respectivamente, no Grupo I, e de 55,3%, 83,5% e 92,4%, respectivamente, no Grupo II, com diferença estatisticamente significativa (p = 0,041). Conclusões Ambos os tratamentos promoveram recanalização. Houve recanalização mais precoce no grupo de pacientes que utilizaram a rivaroxabana

Deep venous thrombosis (DVT) strikes around ten million people worldwide every year and is associated with major complications including pulmonary embolism and post-thrombotic syndrome. Anticoagulation is the standard treatment, with administration of heparins, vitamin K antagonists, fondaparinux, or, more recently, direct oral anticoagulants (DOACs). Anticoagulants reduce thrombus progression and facilitate natural thrombolytic mechanisms, leading to a phenomenon known as recanalization, which can occur in varying degrees and over variable periods of time, under influence from many different factors, including the type of anticoagulation employed. Objectives To evaluate the degree of recanalization and the time taken, by analysis of color Doppler ultrasonography (CDU) reports from patients with DVT treated with DOACs or with heparin + warfarin. Methods A retrospective analysis was conducted of demographic data and CDU reports from patients with DVT who had been treated from January 2009 to December 2016. These patients were classified into two groups, according to the treatment given: Group I (heparin + warfarin): 26 patients; or Group II (rivaroxaban): 51 patients. The primary outcomes assessed were degree of recanalization and time taken. Results Recanalization rates at 30, 90, and 180 days were 10%, 52.5%, and 78.9%, respectively, in Group I, and 55.3%, 83.5%, and 92.4%, respectively, in Group II, with statistically significant difference (p = 0.041). Conclusions Both treatments led to recanalization. Recanalization occurred earlier among patients treated with rivaroxaban

Rivaroxaban or vitamin-K antagonists following early endovascular thrombus removal and stent placement for acute iliofemoral deep vein thrombosis.

BACKGROUND: The optimal anticoagulant following catheter-based therapy of acute iliofemoral deep vein thrombosis (IFDVT) is unknown. METHODS: From the Swiss Venous Stent registry, an ongoing prospective cohort study, we performed a subgroup analysis of patients with acute IFDVT who underwent catheter-based early thrombus removal followed by nitinol stent placement. Duplex ultrasound and Villalta scores were used to determine patency rates and incidence of the post-thrombotic syndrome (PTS) in patients treated with either rivaroxaban (n = 73) or a vitamin K-antagonist (VKA; n = 38) for a minimum duration of 3 months. RESULTS: Mean follow-up duration was 24 ±â€¯19 months (range 3 to 77 months). Anticoagulation therapy was time-limited (3 to 12 months) in 56% of patients (47% in the rivaroxaban group and 58% in the VKA group, p = 0.26), with shorter mean duration of anticoagulation in the rivaroxaban group (180 ±â€¯98 days versus 284 ±â€¯199 days, p = 0.01). Overall, primary and secondary patency rates at 24 months were 82% (95%CI, 71-89%) and 95% (95%CI, 87-98%), respectively, with no difference between the rivaroxaban (87% [95%CI, 76-94%] and 95% [95%CI, 85-98%]) and the VKA group (72% [95%CI, 52-86%] and 94% [95%CI, 78-99%]; p > 0.10 for both). Overall, 86 (86%) patients were free from PTS at latest follow-up, with no difference between the rivaroxaban and the VKA groups (57 [85%] versus 29 [88%]; p = 0.76). Two major bleeding complications (1 in each group) occurred in the peri-interventional period, without any major bleeding thereafter. CONCLUSIONS: In patients with acute IFDVT treated with catheter-based early thrombus removal and venous stent placement, the effectiveness and safety of rivaroxaban and VKA appear to be similar. CLINICAL TRIAL REGISTRATION: The study is registered on the National Institutes of Health website (ClinicalTrials.gov; identifier NCT02433054).

Anticoagulantes orais diretos para o tratamento da trombose venosa profunda: revisão de revisões sistemáticas / Direct oral anticoagulants for treatment of deep vein thrombosis: overview of systematic reviews

A number of limitations of standard therapy with warfarin for deep vein thrombosis (DVT) have been established. This overview of systematic reviews presents the baseline results for efficacy and safety of the new direct oral anticoagulants (DOACs) thrombin inhibitors, and activated factor X (Xa) inhibitors in patients with DVT. Searches were run on PubMed and the Cochrane Database of Systematic Reviews. Twenty-three studies were retrieved, and one systematic review was judged eligible. This review scored maximum according to AMSTAR criteria and included 7,596 patients for analysis of thrombin inhibitors and 16,356 patients for analysis of factor Xa inhibitors. The results of the meta-analysis indicate that DOACs are similar for DVT treatment when compared to standard treatment with warfarin. The incidence of major bleeding is somewhat lower in patients treated with factor Xa inhibitors and similar to standard therapy when treated with direct thrombin inhibitors

A terapia padrão com varfarina para a trombose venosa profunda (TVP) tem uma série de limitações já estabelecidas. Essa revisão de revisões sistemáticas elenca os principais resultados de eficácia e segurança dos anticoagulantes orais diretos (DOACs), inibidores da trombina e do fator X ativado (Xa), em pacientes com TVP. A pesquisa foi realizada nas bases PubMed e Cochrane Database of Systematic Reviews. Foram recuperados 23 estudos, e uma revisão sistemática foi considerada elegível. Essa revisão atingiu escore máximo no AMSTAR e incluiu 7.596 pacientes para análise dos inibidores da trombina e 16.356 pacientes para a análise dos inibidores do fator Xa. Os resultados da metanálise indicam que os DOACs apresentam eficácia similar à terapia padrão no tratamento da TVP. A incidência de sangramento maior é um pouco menor nos pacientes tratados com os inibidores do fator Xa e similar à terapia padrão no tratamento com inibidores diretos da trombina

[Comparison of therapeutics effects of transcatheter arterial chemoembolization combined with iodine-125 seed implantation and sorafenib for the treatment of hepatocellular carcinoma with portal vein tumor thrombosis].

Objective: To explore the factors affecting the prognosis of patients with hepatocellular carcinoma (HCC) combined with portal vein tumor thrombosis (PVTT), and to analyze the clinical value of transcatheter arterial chemoembolization (TACE) combined with iodine-125 seed implantation in such patients. Methods: A retrospective analysis of 53 patients with HCC combined with PVTT was performed. In the study group, 32 cases were treated with TACE combined with iodine-125 seed implantation, and 21 cases in the control group were treated with TACE combined with sorafenib. Survival analysis was carried out on eight factors such as gender, age, Child-Pugh classification, alpha fetoprotein level, portal vein tumor thrombosis (PVTT) type, forms of liver tumor, extra-hepatic metastasis and treatment modalities. The efficacy of TACE combined with iodine-125 seed implantation and TACE combined with sorafenib was further compared. The χ (2) test was used to evaluate the efficacy of the two groups. A single factor survival analysis was calculated by Kaplan-Meier estimator and multifactor survival analysis by Cox proportional hazards model. Results: All 53 patients were successfully treated. The median tumor progression time (mTTP) and median overall survival (mOS) were 8 months and 11 months, respectively. The disease control rate (DCR) of the study group for PVTT was 93.8%, which was significantly higher than that of the control group (61.9%, χ (2) = 6.448, P = 0.011). The difference was statistically significant; the objective remission rate of the study group for PVTT was 75.0%. Significantly higher than 9.5% in the control group, P < 0.05, the difference was statistically significant; the DCR of the primary tumor in the study group was 50.0%, which was lower than the 70.0% of the PVTT in the control group, P = 0.231, the difference was not statistically significant. The progression of primary HCC lesions in patients with multivariate survival analysis: Child-Pugh grade A patients were compared to grade B [Hazard ratio (HR) = 0.236, P = 0.003]; no extra-hepatic metastasis (HR = 0.258, P = 0.002); and TACE combined with iodine-125 seed implantation group compared with TACE combined sorafenib group (HR = 0.372, P = 0.002), the differences were statistically significant. Multivariate survival analysis of patients with overall survival: AFP < 400 ng/mL vs. AFP≥400 ng/mL (HR = 0.389, P = 0.030); Child-Pugh grade A vs. B (HR = 0.263, P = 0.006); and no extra-hepatic metastasis (HR = 0.306, P = 0.006), the differences were statistically significant. Conclusion: TACE combined with iodine-125 seed implantation for the treatment of HCC with PVTT can effectively control the progression of PVTT and intrahepatic lesions and improve the prognosis of patients.

Paciente con trombosis venosa profunda recidivante por factor V Leiden y respuesta al tratamiento homeopático / Patient with recurrent deep venous thrombosis by factor V Leiden and response to homeopathic treatment

El tromboembolismo venoso (TEV) es un problema de salud significativo, con morbimortalidad cercana al 30%. El factor V Leiden (FVL) es una forma "mutada" del factor V normal que se inactiva 10 veces más lentamente, produciendo estados de hipercoagulación y trombosis. En este artículo se presenta el caso de una mujer de 23 años de edad en quien, a raíz de un episodio de TVP se diagnosticó su condición de portadora de enfermedad por FVL de carácter homocigota. Transcurridos 8 años del primer episodio y estando aún bajo tratamiento convencional, el alto nivel de dímeroD (DD) señalaba alto riesgo de sufrir nuevos episodios de TVP. En ese momento se inició tratamiento con medicación homeopática unicista constitucional, en baja dinamización y dosis diarias, observándose una rápida caída en las cifras de DD cambiando así el pronóstico de futuras recidivas y llevando a los hematólogos a suspender el tratamiento convencional. No hubo recidivas hasta el presente y el Doppler venoso muestra rehabilitación del lecho venoso. (AU)

Venous thromboembolism (VTE) is a significant health problem with morbidity and mortality around 30%. Factor V Leiden (FVL) is a "mutated" form of the normal factor V which is inactivated 10 times slower causing hypercoagulation states and thrombosis. The present articles describes the case of a 23-year-old women in whom that status of homozygous was diagnosed on the occasion of a VTE episode. High dimer-D (DD) levels 8 years later and still under conventional treatment high pointed to high risk for recurrence of VTE. Homeopathic treatment was started (constitutional unicast) in low potency and daily doses. DD fell rapidly, and thus the prognosis changed, leading hematologists to withdraw conventional treatment. Disease did not relapse to this day and venous Doppler sonography evidenced rehabilitated vein system. (AU)