Diagnosis and treatment of deep vein thrombosis of the lower and upper limbs. 2024 recommendations of the thromboembolic disease group of the Spanish Society of Internal Medicine.

Deep vein thrombosis (DVT) of the limbs is a common disease and causes significant morbidity and mortality. It is frequently the prelude to pulmonary embolism (PE), it can recur in 30% of patients and in 25-40% of cases they can develop post-thrombotic syndrome (PTS), with a significant impact in functional status and quality of life. This document contains the recommendations on the diagnosis and treatment of acute DVT from the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI). PE and thrombosis of unusual venous territories (cerebral, renal, mesenteric, superficial, etc.) are outside its scope, as well as thrombosis associated with catheter and thrombosis associated with cancer, which due to their peculiarities will be the subject of other positioning documents of the Thromboembolic Disease group of the Spanish Society of Internal Medicine (SEMI).

[Translated article] Risk of venous thromboembolism in thromboprophylaxis between aspirin and low molecular weight heparins after total hip arthroplasty or total knee arthroplasty: Systematic review and meta-analysis.

INTRODUCTION: The aim of this study was to evaluate the efficacy of aspirin versus low molecular weight heparins (LMWH) for the prophylaxis of venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing total knee arthroplasty (TKA) and/or total hip arthroplasty (THA). MATERIALS AND METHODS: Systematic review and meta-analysis. Sixteen studies were selected. The risk of VTE, DVT and PE were analysed. Mortality, risk of bleeding and surgical wound complications was also analysed. RESULTS: 248,461 patients were included. 176,406 patients with thromboprophylaxis with LMWH and 72,055 patients with aspirin thromboprophylaxis. There were no significant differences in the risk of VTE (OR=0.93; 95% CI: 0.69-1.26; p=0.64), DVT (OR=0.72; 95% CI: 0.43-1.20; p=0.21) or PE (OR=1.13; 95% CI: 0.86-1.49; p=0.38) between both groups. No significant differences were found in mortality (p=0.30), bleeding (p=0.22), or complications in the surgical wound (p=0.85) between both groups. These same findings were found in the sub-analysis of only randomised clinical trials (p>0.05). CONCLUSIONS: No increased risk of PE, DVT, or VTE was found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis. There was also no greater mortality, greater bleeding, or greater complications in the surgical wound found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis.

Sobreexpresión del factor VIII, riesgo de trombosis y tratamiento / Overexpression of factor VIII: risk for thrombosis and treatment

Introducción: la trombosis venosa profunda (TVP) es una enfermedad multifactorial, la cual se ha relacionado con estados de hipercoagulabilidad, alteraciones del flujo sanguíneo y lesiones vasculares endoteliales. Se ha estimado una tasa de incidencia de 1 a 2 casos por mil habitantes año, y casi 2 millones de nuevos casos anuales en Estados Unidos. Existen factores de riesgo establecidos y las trombofilias parecen ocupar un lugar importante en su etiología y los estados de hipercoagulabilidad secundarios a niveles elevados de factor de coagulación VIII asociado a disfunción endotelial, y al incremento de adhesión plaquetaria confieren también una gran predisposición a la aparición de trombosis. Presentación del caso: paciente de 24 años de edad, sin antecedentes de importancia. Consulta por una masa indurada en región axilar derecha, que resultó ser TVP de la vena yugular externa, confluente yugulosubclavio, vena supraclavicular axilar y humeral con alto riesgo de embolización; a su vez se documentó tromboembolia pulmonar y se sospechó trombosis cerebral. La búsqueda de estados procoagulantes no arrojó ningún resultado, posteriormente se mide Factor VIII con sobreexpresión de 223% del valor normal y tras una revisión literaria del tratamiento documentada en el presente artículo se determina que el tratamiento más adecuado es warfarina

Introduction: Deep vein thrombosis (DVT) is a multifactorial medical condition that has been related to hypercoagulable states, alterations in blood flow and lesions in vessel endothelium. The incidence of DVT ranges between 1 and 2 cases per 1000 people and almost two million new cases per year in the United States. Some risk factors have been identified. Thrombophilias seem to play an important role in DVT etiology. Hypercoagulability states secondary to high blood coagulation factor VIII levels associated with endothelial dysfunction and increased platelet adhesion, pose a higher predisposition for thrombosis. Case report: we present the case of a 24-year-old male patient, with no relevant past history, who presented with an indurated mass in the right axillary region, which turned out to be a DVT of the external jugular vein, jugulo-subclavian confluence, supraclavicular, axillary and humeral veins with high risk of embolism. Pulmonary thromboembolism was documented and cerebral venous thrombosis was suspected. The search for procoagulant states yielded no results. Factor VIII levels were measured revealing an overexpression of factor VIII at 223% [normal range 50 ­ 200%]. A literature review determined warfarin to be the proper treatment

Estudio coste-efectividad del diagnóstico de trombosis venosa profunda en el medio hospitalario / Cost-effectiveness study of deep venous thrombosis diagnosis at the hospital setting

Introducción y objetivos: la trombosis venosa profunda (tVP) supone una importante carga económica. nuestro objetivo primario es comparar dos estrategias diagnósticas en cuanto a costes y a efectividad: la prueba del dímero d a todos los pacientes con sospecha con condicionarla a la probabilidad clínica pretest. el secundario, analizar el coste del diagnóstico en nuestro centro y los factores asociados a su presentación. Material y métodos: estudio prospectivo de los pacientes atendidos con sospecha de tVP de extremidad inferior entre mayo y octubre de 2019. Se analizaron las variables de la escala de Wells, el teP asociado, el dímero d, el resultado del eco Doppler y los costes (atención en urgencias, el reactivo del dímero d y la realización de un eco Doppler, obtenidos del Boletín oficial de la comunidad y de la unidad de cobros del hospital). el análisis estadístico se realizó con SPSS, pruebas de χ2 y el test exacto de Fisher. Resultados: se estudiaron 249 pacientes. 116 (46,59 %) presentaron tVP. La edad media fue de 70 años (21-95). aquellos con tVP presentaron con más frecuencia: sexo masculino (52,6 % frente a 39,8 %, p = 0,04), cáncer (29,3 % frente a 16,5 %, p = 0,016), dolor (80,2 % frente a 45,1 %, p < 0,001), edema (93,1 % frente a 57,1 %, p < 0,001), empastamiento (72,4 % frente a 14,3 %, p < 0,001), teP (25,9 % frente a 13,5 %, p = 0,014), menor diagnóstico alternativo (0,9 % frente a 62,4 %, p < 0,001) y menor obesidad (7,8 % frente a 18,8 %, p = 0,011). el gasto generado fue de 192,49 euros por paciente. Para el objetivo primario se analizaron a 144 pacientes (aquellos con dímero d). La estrategia 1 generó un gasto de 190,41 euros por paciente, con una sensibilidad del 100 % y una especificidad del 7,1 %; la estrategia 2, 188,51 euros por paciente, con una sensibilidad del 88,3 % y una especificidad del 78,5 %. ambas estrategias son un 1 % y un 2 % más económicas que el gasto generado, respectivamente...(AU)

Introduction and objective: deep venous thrombosis (dVt) is a significant economic burden. the study primaryendpoint is to compare two diagnostic strategies in terms of cost and effectiveness: d-dimer to all patients withsuspected dVt vs conditioning it to the pre-test clinical probability; the secondary endpoint is to analyze the costof dVt diagnosis in our center and the factors associated with its presentation. Material and methods: this was a prospective study of patients with suspected dVt of lower extremities con-ducted between may and october 2019. the variables of the Wells scale, associated Pte, d-dimer levels, dopplerechocardiography and costs (emergency care, d-dimer and doppler echocardiography obtained from the regionofficial Bulletin and the hospital billing unit) were analyzed. the statistical analysis was performed with SPSS, thechi-square test, and Fisher's exact test. Results: a total of 249 patients were studied, 116 of whom (46.59 %) presented with dVt. the mean age was70 years (21-95). those with dVt were predominantly men (52.6 % vs 39.8 %; p = .04), had cancer (29.3 %vs 16.5 %, p = 0.016), pain (80.2 % vs 45.1 %; p < .001), edema (93.1 % vs 57.1 %, p < .001), slurring (72.4 % vs14.3 %; p < .001), Pte (25.9 % vs 13.5 %, p = .014), less alternative diagnosis (0.9 % vs 62.4 %; p = .001) and lessobesity (7.8 % vs 18.8 %; p = .011). the cost generated was € 192.49 per patient. Regarding the primary endpoint,144 patients (those with d-dimer) were analyzed. Strategy #1 resulted in a cost of €190.41 per patient with100 % sensitivity and 7.1 % specificity; strategy # 2, resulted in a cost of €188.51/patient, with 88.3 % and 78.5 %sensitivity and specificity rates, respectively. Both strategies are 1 % and 2 % cheaper than the cost generated.Conclusion: the application of diagnostic algorithms for suspected dVt is cost-effective, so its use should begeneralized.(AU)

Risk of venous thromboembolism in thromboprophylaxis between aspirin and low molecular weight heparins after total hip arthroplasty or total knee arthroplasty: Systematic review and meta-analysis. / Riesgo de tromboembolismo venoso en la tromboprofilaxis entre aspirina y heparinas de bajo peso molecular tras una artroplastia total de cadera o artroplastia total de rodilla. Revisión sistemática y metaanálisis.

INTRODUCTION: The aim of this study was to evaluate the efficacy of aspirin versus low molecular weight heparins (LMWH) for the prophylaxis of venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing total knee arthroplasty (TKA) and/or total hip arthroplasty (THA). MATERIALS AND METHODS: Systematic review and meta-analysis. Sixteen studies were selected. The risk of VTE, DVT and PE were analyzed. Mortality, risk of bleeding and surgical wound complications was also analyzed. RESULTS: 248,461 patients were included. 176,406 patients with thromboprophylaxis with LMWH and 72,055 patients with aspirin thromboprophylaxis. There were no significant differences in the risk of VTE (OR = 0.93; 95% CI: 0.69-1.26; P = .64), DVT (OR = 0.72; 95% CI: 0.43-1.20; P = .21) or PE (OR = 1.13; 95% CI: 0.86-1.49; P = .38) between both groups. No significant differences were found in mortality (P = .30), bleeding (P = .22), or complications in the surgical wound (P = .85) between both groups. These same findings were found in the sub-analysis of only randomized clinical trials (P>.05). CONCLUSIONS: No increased risk of PE, DVT, or VTE was found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis. There was also no greater mortality, greater bleeding, or greater complications in the surgical wound found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis.

Flegmasia cerúlea dolorosa en paciente con trombocitopenia inmune primaria: un gran reto terapéutico / Phlegmasia cerulea dolorosa and primary immune thrombocytopenia: a therapeutic challenge

Introducción: la flegmasia cerúlea dolorosa resulta de una trombosis venosa masiva aguda que provoca unaobstrucción del drenaje venoso de una extremidad y se asocia con un alto grado de morbilidad.Caso clínico: presentamos el caso de un paciente con fl egmasia cerúlea dolorosa y múltiples factores de riesgopara desarrollarla, quien fue llevado a trombólisis dirigida por catéter, con lo que se logró salvar la extremidad.Discusión: la fl egmasia cerúlea dolorosa es una entidad poco frecuente que puede progresar de manera rápiday comprometer la vitalidad de la extremidad afectada o llevar a desenlaces fatales, por lo que requiere una prontasospecha y una intervención emergente. La terapia antitrombótica sigue siendo el manejo de elección.(AU)

Introduction: phlegmasia cerulea dolorosa results from acute massive venous thrombosis that causes obstructionof the venous drainage of an extremity, and it’s associated with a high morbidity.Case report: we present the case of a patient with phlegmasia cerulea dolorosa and multiple risk factors fordeveloping it, who was taken to catheter-directed thrombolysis successfully.Discussion: phlegmasia cerulea dolorosathis is a rare entity that can progress rapidly and compromise the vitalityof the limb or lead to fatal outcomes, which requires early suspicion and emergency intervention. Antithrombotictherapy continues to be the ideal treatment.(AU)

El uso de artroscopia no aumenta la incidencia de complicaciones en el manejo de fracturas de mesetas tibiales Schatzker IV-VI / The use of arthroscopy does not increase the incidence of complications in the management of Schatzker IV-VI tibial plateau fractures

Antecedentes y objetivo: El uso de asistencia artroscopica en fracturas de mesetas tibiales tipos I-III según la clasificación de Schatzker se ha popularizado; sin embargo aún existe controversia con respecto a su uso en fracturas Schatzker IV-VI por el potencial riesgo de complicaciones. El objetivo de este trabajo es comparar la tasa de complicaciones intra o postoperatorias entre pacientes con fracturas de mesetas tibiales de este tipo tratados con y sin artroscopia al momento de la reducción y osteosíntesis definitiva. Materiales y métodos: Estudio de cohortes retrospectivo. Se incluyeron pacientes con diagnóstico de fractura de mesetas tibiales Schatzker IV-VI, sometidos a reducción y osteosíntesis definitiva, y al manejo de lesiones asociadas con o sin el uso de artroscopia evaluando la aparición de síndrome compartimental, trombosis venosa profunda e infección relacionada a fractura con seguimiento mínimo de 12 meses posterior a la cirugía definitiva. Resultados: Se incluyeron 288 pacientes: 86 operados con asistencia artroscópica y 202 sin asistencia artroscópica. La tasa de complicaciones total en el grupo con y sin asistencia artroscópica fue del 18,60 y 26,73%, respectivamente (p=0,141). No hubo asociación estadísticamente significativa entre el uso de asistencia artroscópica y el desarrollo de las complicaciones analizadas. Discusión y conclusiones: El uso de artroscopia de rodilla como apoyo de la reducción o como adyuvancia para el tratamiento simultáneo de lesiones intraarticulares concomitantes no aumentó el riesgo de complicaciones en el postoperatorio inmediato ni tras 12 meses de seguimiento.(AU)

Background and objective: The use of arthroscopy for tibial plateau fractures type I, II and III according to Schatzker classification has increased, yet its employment for tibial plateau fractures Schatzker IV, V and VI is controversial due to the potential risk of compartment syndrome, deep vein thrombosis and infection. We aimed to compare the rate of operative and postoperative complications among patients with these types of tibial plateau fractures treated with and without arthroscopy at the time of definitive reduction and osteosynthesis. Methods: Retrospective cohort study. Patients with diagnosis of tibial plateau fracture Schatzker IV, V or VI who underwent reduction and definitive osteosynthesis with or without the use of arthroscopy were included. The development of compartment syndrome, deep vein thrombosis, and fracture-related infection was evaluated up to 12 months after the definitive surgery. Results: Two hundred eighty-eight patients were included: 86 with arthroscopic assistance and 202 without it. The overall complication rate in the group with and without arthroscopic assistance was 18.60% and 26.73%, respectively (P=.141). No statistical association was found between the use of arthroscopic assistance and the development of the analyzed complications. Discussion and conclusion: The use of arthroscopy to support reduction or addressing concomitant intra-articular injuries did not increase the risk of complications in patients with high-energy tibial plateau fractures at 12 months of follow up.(AU)

[Translated article] The use of arthroscopy does not increase the incidence of complications in the management of Schatzker IV–VI tibial plateau fractures / El uso de artroscopia no aumenta la incidencia de complicaciones en el manejo de fracturas de mesetas tibiales Schatzker IV-VI

Antecedentes y objetivo: El uso de asistencia artroscopica en fracturas de mesetas tibiales tipos I-III según la clasificación de Schatzker se ha popularizado; sin embargo aún existe controversia con respecto a su uso en fracturas Schatzker IV-VI por el potencial riesgo de complicaciones. El objetivo de este trabajo es comparar la tasa de complicaciones intra o postoperatorias entre pacientes con fracturas de mesetas tibiales de este tipo tratados con y sin artroscopia al momento de la reducción y osteosíntesis definitiva. Materiales y métodos: Estudio de cohortes retrospectivo. Se incluyeron pacientes con diagnóstico de fractura de mesetas tibiales Schatzker IV-VI, sometidos a reducción y osteosíntesis definitiva, y al manejo de lesiones asociadas con o sin el uso de artroscopia evaluando la aparición de síndrome compartimental, trombosis venosa profunda e infección relacionada a fractura con seguimiento mínimo de 12 meses posterior a la cirugía definitiva. Resultados: Se incluyeron 288 pacientes: 86 operados con asistencia artroscópica y 202 sin asistencia artroscópica. La tasa de complicaciones total en el grupo con y sin asistencia artroscópica fue del 18,60 y 26,73%, respectivamente (p=0,141). No hubo asociación estadísticamente significativa entre el uso de asistencia artroscópica y el desarrollo de las complicaciones analizadas. Discusión y conclusiones: El uso de artroscopia de rodilla como apoyo de la reducción o como adyuvancia para el tratamiento simultáneo de lesiones intraarticulares concomitantes no aumentó el riesgo de complicaciones en el postoperatorio inmediato ni tras 12 meses de seguimiento.(AU)

Background and objective: The use of arthroscopy for tibial plateau fractures type I, II and III according to Schatzker classification has increased, yet its employment for tibial plateau fractures Schatzker IV, V and VI is controversial due to the potential risk of compartment syndrome, deep vein thrombosis and infection. We aimed to compare the rate of operative and postoperative complications among patients with these types of tibial plateau fractures treated with and without arthroscopy at the time of definitive reduction and osteosynthesis. Methods: Retrospective cohort study. Patients with diagnosis of tibial plateau fracture Schatzker IV, V or VI who underwent reduction and definitive osteosynthesis with or without the use of arthroscopy were included. The development of compartment syndrome, deep vein thrombosis, and fracture-related infection was evaluated up to 12 months after the definitive surgery. Results: Two hundred eighty-eight patients were included: 86 with arthroscopic assistance and 202 without it. The overall complication rate in the group with and without arthroscopic assistance was 18.60% and 26.73%, respectively (P=.141). No statistical association was found between the use of arthroscopic assistance and the development of the analyzed complications. Discussion and conclusion: The use of arthroscopy to support reduction or addressing concomitant intra-articular injuries did not increase the risk of complications in patients with high-energy tibial plateau fractures at 12 months of follow up.(AU)

Riesgo de recurrencia de la trombosis en pacientes con tromboembolia venosa asociada a COVID-19 y a cirugía / Risk of thrombosis recurrence among patients with COVID-19- and surgery-associated venous thromboembolism

Introducción La cirugía reciente es un factor de riesgo transitorio mayor y conocido de tromboembolia venosa (TEV) debido al bajo riesgo de recurrencia de la TEV una vez suspendida la anticoagulación. Por otro lado, se desconoce el riesgo de recurrencia de la TEV en los pacientes con TEV asociada a COVID-19. El objetivo de este estudio consistió en comparar el riesgo de recurrencia de la TEV entre pacientes con TEV asociada a COVID-19 y a cirugía. Método Se realizó un estudio prospectivo, observacional y unicéntrico en el que participaron pacientes consecutivos diagnosticados de TEV en un hospital terciario entre enero de 2020 y mayo de 2022 y que fueron objeto de seguimiento durante un mínimo de 90 días. Se evaluaron las características iniciales, el cuadro clínico y los resultados clínicos. Se compararon las incidencias de recurrencia de la TEV, hemorragias y muertes entre ambos grupos. Resultado En el estudio se incluyó a un total de 344 pacientes: 111 con TEV asociada a cirugía y 233 con TEV asociada a COVID-19. Entre los pacientes con TEV asociada a COVID-19 hubo una mayor frecuencia de varones (65,7 vs. 48,6%, p = 0,003). La recurrencia de la TEV fue de 3% en los pacientes con COVID-19 y de 5,4% en los pacientes quirúrgicos, sin diferencias significativas (p = 0,364). La tasa de incidencia de TEV recurrente fue de 1,25 y 2,29 por 1.000 personas-meses en los pacientes con COVID-19 y quirúrgicos, respectivamente, sin diferencias significativas (p = 0,29). En el análisis multifactorial, la COVID-19 se asoció a una mayor mortalidad (HR = 2,34; IC 95%, 1,19-4,58), pero no a un mayor riesgo de recurrencia (HR = 0,52; IC 95%, 0,17-1,61). En el análisis multifactorial de riesgos competitivos no se observaron diferencias en cuanto a recurrencias (SHR = 0,82; IC 95%, 0,40-2,05). Conclusiones El riesgo de recurrencia fue bajo en los pacientes con TEV asociada a COVID-19 y a cirugía, sin diferencias entre ambos grupos (AU)

Introduction Recent surgery is a well-known major transient risk factor for venous thromboembolism (VTE) due to the low risk of VTE recurrence after anticoagulation is discontinued. On the other hand, the risk of VTE recurrence among patients with COVID-19-associated VTE is unknown. This study aimed to compare the risk of VTE recurrence between patients with COVID-19- and surgery-associated VTE. Methods A prospective observational single-center study was performed including consecutive patients diagnosed with VTE in a tertiary hospital from January 2020 to May 2022 and followed up for at least 90 days. Baseline characteristics, clinical presentation, and outcomes were assessed. The incidence of VTE recurrence, bleeding, and death was compared between both groups. Result A total of 344 patients were included in the study: 111 patients with surgery-associated VTE and 233 patients with COVID-19-associated VTE. Patients with COVID-19-associated VTE were more frequently men (65.7% vs 48.6%, p = 0.003). VTE recurrence was 3% among COVID-19 patients and 5.4% among surgical patients, with no significant differences (p = 0.364). The incidence rate of recurrent VTE was 1.25 per 1000 person-months in COVID-19 patients and 2.29 person-months in surgical patients, without significant differences (p = 0.29). In the multivariate analysis, COVID-19 was associated with higher mortality (HR 2.34; 95% CI 1.19-4.58), but not with a higher risk of recurrence (HR 0.52; 95% CI 0.17-1.61). No differences were found in recurrence in the multivariate competing risk analysis (SHR 0.82; 95% CI 0.40 – 2.05). Conclusions In patients with COVID-19 and surgery-associated VTE, the risk of recurrence was low, with no differences between both groups (AU)

[Translated article] The use of arthroscopy does not increase the incidence of complications in the management of Schatzker IV-VI tibial plateau fractures.

BACKGROUND AND OBJECTIVE: The use of arthroscopy for tibial plateau fractures type I, II and III according to Schatzker classification has increased, yet its employment for tibial plateau fractures Schatzker IV, V and VI is controversial due to the potential risk of compartment syndrome, deep vein thrombosis and infection. We aimed to compare the rate of operative and postoperative complications among patients with these types of tibial plateau fractures treated with and without arthroscopy at the time of definitive reduction and osteosynthesis. METHODS: Retrospective cohort study. Patients with diagnosis of tibial plateau fracture Schatzker IV, V or VI who underwent reduction and definitive osteosynthesis with or without the use of arthroscopy were included. The development of compartment syndrome, deep vein thrombosis, and fracture-related infection was evaluated up to 12 months after the definitive surgery. RESULTS: Two hundred eighty-eight patients were included: 86 with arthroscopic assistance and 202 without it. The overall complication rate in the group with and without arthroscopic assistance was 18.60% and 26.73%, respectively (p=.141). No statistical association was found between the use of arthroscopic assistance and the development of the analysed complications. DISCUSSION AND CONCLUSION: The use of arthroscopy to support reduction or addressing concomitant intra-articular injuries did not increase the risk of complications in patients with high-energy tibial plateau fractures at 12 months of follow up.

Risk of thrombosis recurrence among patients with COVID-19 and surgery-associated venous thromboembolism.

INTRODUCTION: Recent surgery is a well-known major transient risk factor for venous thromboembolism (VTE) due to the low risk of VTE recurrence after anticoagulation is discontinued. On the other hand, the risk of VTE recurrence among patients with COVID-19-associated VTE is unknown. This study aimed to compare the risk of VTE recurrence between patients with COVID-19- and surgery-associated VTE. METHODS: A prospective observational single-center study was performed including consecutive patients diagnosed with VTE in a tertiary hospital from January 2020 to May 2022 and followed up for at least 90 days. Baseline characteristics, clinical presentation, and outcomes were assessed. The incidence of VTE recurrence, bleeding, and death was compared between both groups. RESULTS: A total of 344 patients were included in the study: 111 patients with surgery-associated VTE and 233 patients with COVID-19-associated VTE. Patients with COVID-19-associated VTE were more frequently men (65.7% vs 48.6%, p =  0.003). VTE recurrence was 3% among COVID-19 patients and 5.4% among surgical patients, with no significant differences (p =  0.364). The incidence rate of recurrent VTE was 1.25 per 1000 person-months in COVID-19 patients and 2.29 person-months in surgical patients, without significant differences (p =  0.29). In the multivariate analysis, COVID-19 was associated with higher mortality (HR 2.34; 95% CI 1.19-4.58), but not with a higher risk of recurrence (HR 0.52; 95% CI 0.17-1.61). No differences were found in recurrence in the multivariate competing risk analysis (SHR 0.82; 95% CI 0.40-2.05). CONCLUSIONS: In patients with COVID-19 and surgery-associated VTE, the risk of recurrence was low, with no differences between both groups.

Características clínicas y forma de presentación en pacientes con enfermedad tromboembólica venosa y dímero-D negativo o débilmente positivo / Clinical characteristics and presentation form in patients with venous thromboembolism and negative or weakly positive D-dimer

Introducción: El dímero-D presenta un elevado valor predictivo negativo (VPN) para el diagnóstico de enfermedad tromboembólica venosa (ETV). Sin embargo, se ha descrito ETV en presencia de valores normales de dímero-D.Pacientes y métodosEstudio observacional prospectivo en pacientes con ETV en el Hospital Gregorio Marañón entre 2001-2022 que compara las características de presentación clínica en función de los niveles de dímero-D (< 500 ng/mL vs. ≥ 500 ng/mL).ResultadosDel total de 2.582 pacientes, 333 pacientes (12,9%) presentaron dímero-D negativo o débilmente positivo. Estos eran significativamente más jóvenes (57,9 vs. 65,3 años), con menor prevalencia de comorbilidades (cardiopatía isquémica, demencia y enfermedad renal crónica), mayor historia familiar de ETV (8,4% vs. 5,2%) y trombofilia (11,7% vs. 7,8%). Presentaron significativamente menor disnea (57,6% vs. 75,4%), síncope (3% vs. 13,5%), menor carga trombótica, elevación de Nt-pro-BNP (22,0% vs. 48,2%) y dilatación del ventrículo derecho (8,1% vs. 30,0%).ConclusiónLos pacientes con ETV y niveles bajos de dímero-D al diagnóstico fueron más jóvenes, con presentación clínica más leve y menor carga trombótica; pero presentaron mayor prevalencia de trombofilia e historia familiar de ETV. (AU)

Introduction: D-dimer has a high negative predictive value for the diagnosis of venous thromboembolic disease (VTE). However, VTE has been reported in the presence of normal D-dimer values.MethodsThis is a prospective observational study in patients with VTE from Hospital Gregorio Marañón between 2001 and 2022, comparing the characteristics of clinical presentation based on D-dimer levels (<500 ng/mL vs. ≥500 ng/mL).ResultsA total of 2582 patients were found, 333 patients (12.9%) presented negative or weakly positive D-dimer levels. They were significantly younger (57.9 vs. 65.3 years), with a lower prevalence of comorbidities (ischemic heart disease, dementia, and chronic kidney disease), and a greater family history of VTE (8.4% vs. 5.2%) and thrombophilia (11.7% vs. 7.8%). They presented significantly less dyspnea (57.6% vs. 75.4%), syncope (3% vs. 13.5%), less thrombotic load, elevated NT-pro-BNP (22.0% vs. 48.2%), and right ventricle dilatation (8.1% vs. 30.0%).ConclusionPatients with VTE and low D-dimer levels at diagnosis were younger, with milder clinical presentation and lower thrombotic load; but they presented a higher prevalence of thrombophilia and a family history of VTE. (AU)

Trombosis venosa profunda durante el periodo de vacunación frente al virus SARS-CoV-2 / Deep vein thrombosis during vaccination against SARS-CoV-2 period

Objetivos: tras el inicio de la vacunación frente al SARS-CoV-2 una de las entidades de enfermedad tromboembólica venosa (ETEV) más frecuente, la trombosis venosa profunda (TVP), apenas ha sido documentada. Analizamos los episodios de TVP durante el periodo de vacunación frente al SARS-CoV-2. Material y métodos: análisis unicéntrico retrospectivo que incluye pacientes diagnosticados de TVP (enero-septiembre de 2021). Se estratifican en dos grupos: vacunados y no vacunados frente al SARS-CoV-2 en los 28 días anteriores a iniciar la sintomatología de TVP. Variable principal: gravedad de TVP (tromboembolismo pulmonar [TEP] o necesidad de ingreso). Variables secundarias: factores de riesgo para TVP (idiopática, antecedente de ETEV, encamamiento, traumatismo, cirugía, trombofilia, hormonoterapia y neoplasia). Resultados: 192 pacientes diagnosticados de TVP, 42 (21,9 %) vacunados y 150 (78,1 %) no vacunados. Desarrollaron TEP el 52,4 % de los vacunados y el 62,7 % de los controles (p = 0,228). Necesidad de ingreso: 52,4 % de los vacunados frente al 62,4 % de los no vacunados) (p = 0,536); TVP idiopática: 28,6 % de los vacunados frente al 48 % de los no vacunados) (p = 0,025); antecedente de ETEV: 21,4 % de los vacunados frente al 17,3 % de los controles) (p = 0,543); encamamiento: 7,1 % de los vacunados frente al 12,7 % de los no vacunados (p = 0,418); traumatismo: 4,8 % de los vacunados frente al 6 % de los controles (p = 1); cirugía: 4,8 % de los vacunados frente al 1,3 % de los no vacunados (p = 0,209); trombofilia: 16,7 % de los vacunados frente al 4 % de los controles (p = 0,009); hormonoterapia: 9,5 % de los vacunados frente al 3,3 % de los no vacunados (p = 0,107); neoplasia: 28,6 % de los vacunados frente al 18,7 % de los no vacunados (p = 0,162). Se apreció un OR 6,10 (IC 95 %, 1,52-24,37) para TVP en pacientes vacunados con trombofilia en el análisis multivariante. Conclusión: la vacunación frente SARS-CoV-2 no parece aumentar la gravedad de la TVP...(AU)

Objectives: since the beginning of vaccination against SARS-CoV-2 virus one of the most frequent entities ofvenous thromboembolism (VTE), deep vein thrombosis (DVT), has been scarcely documented. We analyze DVTepisodes during vaccination against SARS-CoV-2 period.Material and methods: retrospective unicenter analysis including patients diagnosed with DVT (January -Septem-ber 2021). Patients were divided into two groups, vaccinated and unvaccinated against SARS-CoV-2 28 days priorto DVT symptoms onset. Primary endpoint: DVT severity (pulmonary embolism (PE) and/or hospital admission).Secondary endpoints: DVT risk factors (unprovoked, VTE antecedent, immobilization, trauma, surgery, thrombo-philia, hormone therapy and cancer).Results: there were 192 DVT diagnoses, 42 (21,9 %) vaccinated and 150 (78,1 %) unvaccinated. DVT severity:PE: 52,4 % vaccinated vs. 62,7 % controls (p = 0,228); hospital admission: 52,4 % vaccinated vs. 62,4 % unvac-cinated (p = 0,536); unprovoked DVT: 28,6 % vaccinated vs. 48 % unvaccinated (p = 0,025); VTE antecedent:21,4 % vaccinated vs. 17,3 % unvaccinated (p = 0,543): immobilization: 7,1 % vaccinated vs. 12,7 % unvacci-nated; trauma: 4,8 % vaccinated vs. 6 % unvaccinated (p = 1); surgery: 4,8 % vaccinated vs. 1,3 % unvaccinat-ed (p = 0,209); thrombophilia: 16,7 % vaccinated vs. 4 % unvaccinaed (p = 0,009); hormone theraphy: 9,5 %vaccinated vs. 3,3 % unvaccinated (p = 0,107); cancer: 28,6 % vaccinated vs. 18,7 % unvaccinated (p = 0,162).Multivariate analysis showed a higher risk of DVT in vaccinated patients with thrombophilia, with an OR of6,10 (95 % CI, 1,52-24,37).Conclusion: vaccination against SARS-CoV-2 doesn’t seem to increased DVT severity, although a higher incidenceof DVT in vaccinated patients with thrombophilia was observed.(AU)

The use of arthroscopy does not increase the incidence of complications in the management of Schatzker IV-VI tibial plateau fractures. / El uso de artroscopia no aumenta la incidencia de complicaciones en el manejo de fracturas de mesetas tibiales Schatzker IV-VI.

BACKGROUND AND OBJECTIVE: The use of arthroscopy for tibial plateau fractures type I, II and III according to Schatzker classification has increased, yet its employment for tibial plateau fractures Schatzker IV, V and VI is controversial due to the potential risk of compartment syndrome, deep vein thrombosis and infection. We aimed to compare the rate of operative and postoperative complications among patients with these types of tibial plateau fractures treated with and without arthroscopy at the time of definitive reduction and osteosynthesis. METHODS: Retrospective cohort study. Patients with diagnosis of tibial plateau fracture Schatzker IV, V or VI who underwent reduction and definitive osteosynthesis with or without the use of arthroscopy were included. The development of compartment syndrome, deep vein thrombosis, and fracture-related infection was evaluated up to 12 months after the definitive surgery. RESULTS: Two hundred eighty-eight patients were included: 86 with arthroscopic assistance and 202 without it. The overall complication rate in the group with and without arthroscopic assistance was 18.60% and 26.73%, respectively (P=.141). No statistical association was found between the use of arthroscopic assistance and the development of the analyzed complications. DISCUSSION AND CONCLUSION: The use of arthroscopy to support reduction or addressing concomitant intra-articular injuries did not increase the risk of complications in patients with high-energy tibial plateau fractures at 12 months of follow up.

[Clinical characteristics and presentation form in patients with venous thromboembolism and negative or weakly positive D-dimer]. / Características clínicas y forma de presentación en pacientes con enfermedad tromboembólica venosa y dímero-D negativo o débilmente positivo.

INTRODUCTION: D-dimer has a high negative predictive value for the diagnosis of venous thromboembolic disease (VTE). However, VTE has been reported in the presence of normal D-dimer values. METHODS: This is a prospective observational study in patients with VTE from Hospital Gregorio Marañón between 2001 and 2022, comparing the characteristics of clinical presentation based on D-dimer levels (<500 ng/mL vs. ≥500 ng/mL). RESULTS: A total of 2582 patients were found, 333 patients (12.9%) presented negative or weakly positive D-dimer levels. They were significantly younger (57.9 vs. 65.3 years), with a lower prevalence of comorbidities (ischemic heart disease, dementia, and chronic kidney disease), and a greater family history of VTE (8.4% vs. 5.2%) and thrombophilia (11.7% vs. 7.8%). They presented significantly less dyspnea (57.6% vs. 75.4%), syncope (3% vs. 13.5%), less thrombotic load, elevated NT-pro-BNP (22.0% vs. 48.2%), and right ventricle dilatation (8.1% vs. 30.0%). CONCLUSION: Patients with VTE and low D-dimer levels at diagnosis were younger, with milder clinical presentation and lower thrombotic load; but they presented a higher prevalence of thrombophilia and a family history of VTE.

Caracterización clínica y epidemiológica de pacientes con trombosis venosa profunda y cáncer / Clinical and epidemiological characterization of patients with deep vein thrombosis and cancer

Introducción: La enfermedad tromboembólica venosa es un trastorno en el que se forma un trombo en el interior de las venas, que bloquea el flujo sanguíneo y produce diferentes sintomatologías en función de su localización. Objetivos: Definir las características clínicas y epidemiológicas de los pacientes con trombosis venosa profunda y cáncer. Métodos: Se realizó un estudio descriptivo y retrospectivo de los pacientes que ingresaron en el Servicio de Flebolinfología del Instituto Nacional de Angiología y Cirugía Vascular, con el diagnóstico de trombosis venosa profunda y cáncer, durante el período entre enero y diciembre de 2018. Se estudiaron las siguientes variables: grupos de edad, sexo, diagnóstico al ingreso, factores de riesgo, tipos de cáncer y localización de la trombosis según Eco-Doppler. Resultados: El grupo de edad predominante fue 60-69 años (30,8 por ciento) y prevaleció el sexo femenino (61,5 por ciento). Sobresalió la localización del cáncer en las mamas y la próstata con tres casos cada uno (23,1 por ciento). El factor de riesgo predominante resultó la edad (38,4 por ciento), seguido por la presencia de metástasis (23,1 por ciento). Como sector predominante, según Eco-Doppler, se halló el femoropoplíteo (58,8 por ciento). Conclusiones: La trombosis venosa profunda afecta en gran medida a los pacientes con cáncer. Los más afectados tienen entre 60 y 69 años. Los factores de riesgo predominantes fueron la edad y la presencia de metástasis; y la localización más frecuente, los miembros inferiores, en específico, a nivel del sector femoropoplíteo(AU)

Introduction: Venous thromboembolic disease is a disorder in which a thrombus forms inside the veins, which blocks blood flow and produces different symptoms depending on its location. Objectives: To define the clinical and epidemiological characteristics of patients with deep vein thrombosis and cancer. Methods: A descriptive and retrospective study of patients admitted in the Phlebolymphology Service of the National Institute of Angiology and Vascular Surgery, with the diagnosis of deep vein thrombosis and cancer, was conducted during the period between January and December 2018. The following variables were studied: age groups, sex, diagnosis upon admission, risk factors, types of cancer and location of thrombosis according to Eco-Doppler. Results: The predominant age group was 60-69 years (30.8 percent) and the female sex prevailed (61.5 percent). The location of cancer in the breasts and prostate stood out with three cases each (23.1 percent). The predominant risk factor was age (38.4 percent), followed by the presence of metastases (23.1 percent). As the predominant sector, according to Eco-Doppler, it was found the femoro-popliteal (58.8 percent). Conclusions: Deep vein thrombosis greatly affects cancer patients. The most affected are between 60 and 69 years old. The predominant risk factors were age and the presence of metastases; and the most frequent location, the lower limbs, specifically, at the level of the femoro-popliteal sector(AU)

Trombosis venosa profunda masiva en gestante: la importancia de individualizar el plan de acción / Massive deep vein thrombosis in pregnant women: The importance of individualizing the action plan

El tromboembolismo venoso (TEV), incluida la trombosis venosa profunda (TVP) y la embolia pulmonar (TEP) es una afección potencialmente letal y a tener en cuenta en mujeres embarazadas, donde la situación es favorecida por los cambios fisiológicos característicos de la gestación, el parto y el puerperio. El manejo de esta patología en este tipo de pacientes está basado en la anticoagulación, con los beneficios e inconvenientes que ello implica. Presentamos el caso de una mujer embarazada con TVP masiva e intentamos arrojar luz sobre temas como son la vía de parto (vaginal vs. cesárea) o el manejo del tratamiento (heparina de bajo peso molecular [HBPM] vs. heparina no fraccionada [HNF]) de cara a obtener la situación más segura para la paciente.(AU)

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a potentially lethal condition to be taken into account in pregnant women, where the situation is favored by the characteristic physiological changes of the pregnancy, childbirth and the puerperium. The management of this pathology in this type of patient is based on anticoagulation, with the benefits and drawbacks that this implies. We present the case of a pregnant woman with massive DVT and the issues are discussed, such as the method of delivery (vaginal vs. cesarean section) or the management of treatment (LMWH vs. UFH) in order to obtain the safest situation for the patient.(AU)

Ecografía multiórgano en infección por SARS-COV-2 / Multi-organ ultrasound for SARS-COV-2 disease

Aim: There is growing evidence regarding the imaging ultrasound findings of coronavirus disease 2019 COVID-19. Multi-organ ultrasoundhas played a significant role in the diagnosis and follow-up of thesepatients. The aim of this study was to describe the ultrasound findingsat pulmonary, cardiac and deep venous system of the lower extremities in patients with SARS-COV-2 infection.Material and method: Prospective, cross-sectional, observationalstudy was conducted in patients with confirmed COVID-19 who underwent a multi-organ point-of-care ultrasound (POCUS) examinationduring hospitalization.Results: A total of 107 patients were enrolled. Lung involvement waspresent in 100% of the patients, 93.4% bilaterally involvement. Themost affected lung area was the posteroinferior (94.39%) followed bythe lateral (89.72%). Subpleural consolidations were present in 71%of patients and consolidations larger than 1 cm in 25%. More echographic lung involvement is relational with the degree of respiratoryinsufficiency. Only two patients had proximal deep vein thrombosisin the lower extremities, 27 angiography tomography scan were performed and pulmonary thromboembolism was confirmed in 14 patients. The most frequent echocardiographic findings were impairedleft ventricular relaxation and left ventricular hypertrophy. All patientswith thromboembolic disease had severe or critical echocardiographicpulmonary involvement.Conclusions: Multi-organ POCUS ultrasound may be useful for themanifestations of COVID-19. The degree of lung ultrasound involvement was related to the degree of respiratory failure and to the presence of VTED. The relationship between DVT and PTE was lower thanexpected. Cardiac involvement has little relevance in our series. (AU)

Objetivo: Existe una creciente evidencia con respecto a los hallazgosecográficos y la COVID-19, destacando la ecografía multiórgano parael diagnóstico y el seguimiento de estos pacientes. El objetivo fuedescribir los hallazgos ecográficos a nivel pulmonar, cardiaco y delsistema venoso profundo de extremidades inferiores en pacientes coninfección por SARS-COV-2.Material y Métodos: Estudio prospectivo, transversal y observacionalrealizado en pacientes con COVID-19 confirmado a los que se lesrealizó una ecografía multiórgano en el punto de atención durante lahospitalización.Resultados: Un total de 107 pacientes se inscribieron. El 100% delos pacientes tenían afectación pulmonar (93,4% bilateral). Las zonaspulmonares más afectadas fueron la posteroinferior (94,39%) y la lateral (89,72%). Se observó consolidaciones subpleurales en el 71%de los pacientes y consolidaciones mayores de 1 cm en el 25%. Amayor afectación pulmonar ecográfica, mayor grado de insuficienciarespiratoria. 2 pacientes presentaron TVP proximal en extremidadesinferiores. Se realizaron 27 Angiotomografía computarizada confirmándose tromboembolismo pulmonar en 14 pacientes. Los hallazgosecocardiográficos más frecuentes fueron: alteración de la relajacióndel ventrículo izquierdo e hipertrofia ventricular izquierda. Todos lospacientes con enfermedad tromboembólica tenían una afectación pulmonar ecográfica grave o crítica.Conclusión: la ecografia multiórgano puede ser útil para lasmanifestaciones de la COVID-19. El grado de afectación ecográficapulmonar se relacionó con el grado de insuficiencia respiratoria y conla presencia de ETEV. La relación entre TVP y TEP fue más baja de loesperado. La afectación cardiaca fue poco relevante en nuestra serie. (AU)

Massive deep vein thrombosis in pregnant women: The importance of individualizing the action plan.

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a potentially lethal condition to be taken into account in pregnant women, where the situation is favored by the characteristic physiological changes of the pregnancy, childbirth and the puerperium. The management of this pathology in this type of patient is based on anticoagulation, with the benefits and drawbacks that this implies. We present the case of a pregnant woman with massive DVT and the issues are discussed, such as the method of delivery (vaginal vs. cesarean section) or the management of treatment (LMWH vs. UFH) in order to obtain the safest situation for the patient.