Tumor thrombus in the large veins draining primary pelvic osteosarcoma on cross sectional imaging.

PURPOSE: To evaluate the frequency of tumor thrombus in the large veins draining primary pelvic osteosarcoma on early cross-sectional imaging studies and its effect on patient survival. MATERIALS AND METHODS: Our retrospective study included all patients with primary pelvic osteosarcoma treated at our facility between January 2000 and May 2014, who were ≤ 45 years of age, and had adequate imaging studies and clinical follow up. Four radiologists evaluated for tumor in the large draining veins on initial CT, MRI and PET/CTs. A consensus evaluation by the four radiologists together with findings on operative reports, pathology reports or follow-up imaging was used as the reference standard. RESULTS: Thirty-nine patients with primary pelvic osteosarcoma met final inclusion criteria. Tumor thrombus was identified in the large draining veins in 10 of the 22 (45%) patients who underwent tumor resection and 10 of the 17 (59%) who did not. In the 22 patients who underwent tumor resection, tumor thrombus was significantly associated with worse overall survival (p = 0.03). CONCLUSIONS: Tumor thrombus in the large draining veins is identified in a significant proportion of initial imaging studies in patients with pelvic osteosarcoma, and is associated with worse overall survival in patients who undergo tumor resection.

Risk Factors in Children Older Than 5 Years With Pneumococcal Meningitis: Data From a National Network.

BACKGROUND: The occurrence of meningitis in children >5 years old may be associated with specific predisposing factors that can be anatomic, such as cerebrospinal fluid fistula or breach, or related to genetic susceptibility or N inborn or acquired immunologic defect. This study aimed to assess the anatomical and immunologic risk factors in children >5 years old with pneumococcal meningitis and prospectively enrolled in the French national meningitis network. METHODS: We analyzed all data for children who were 5-15 years old with a diagnosis of pneumococcal meningitis between 2001 and 2013. We describe the frequency and typology of the anatomic or immunologic risk factors, the clinical features and the pneumococcal serotypes. RESULTS: Among the 316 patients with pneumococcal meningitis, the mortality rate was 9.5% and 23.1% of cases presented complications (abscess, coma, hemodynamic failure, thrombophlebitis cerebral or deafness). In total, 108 children (34%) showed risk factors, the most frequent being anatomic: 70 cases (22.8%) were related to a cerebrospinal fluid breach or fistula and 55 (17.9%) to immunodeficiency, primary or acquired. Serotype data were available for 207 pneumococcal isolates (65.5%). The most frequent serotypes were as follows: 3, 18C, 19A and 19F between 2001 and 2009 and 19F, 3, 19A, 12F, 22F, 17F and 24F after 2009. CONCLUSIONS: We describe the largest cohort of children >5 years old with pneumococcal meningitis. One third of the children had risk factors justifying a complete immunologic and radiologic work-up.

Epidemiology and treatment strategies of iliac vein thrombophlebitis.

INTRODUCTION: This study aimed to determine the epidemiology of iliac vein thrombophlebitis and describe gender differences associated with the management of this pathology. METHODS: The 2010 National Inpatient Sample was retrospectively reviewed to include all inpatients with ICD-9 codes identifying iliac vein thrombophlebitis (451.81). Demographics, disposition, anticoagulation, thrombolytics, stent placement, open operative intervention, complications (deep vein thrombosis/pulmonary embolism), and mortality rates were reported. Statistical analysis included descriptive statistics and Student's t-testing with P < 0.05 deemed significant. RESULTS: The incidence of iliac vein thrombophlebitis was 1/1,000,000 people. Men had an average age of 48 ± 20 years and women were significantly older at 59 ± 18 years (P = 0.02). There were no differences in treatment strategies or rates of complications between men and women including pulmonary embolism (23% for males, 16% of females) and deep vein thrombosis (29% for males and 19% for females). Length of stay between groups was not significant (11 ± 20 days for males and 7.7 ± 6 days for females). Overall mortality was 1.5%. CONCLUSION: Iliac vein thrombophlebitis is a rare disease. Females who develop iliac vein thrombophlebitis are significantly older than their male counterparts. The rates of deep vein thrombosis, pulmonary embolism, and interventional strategies are not different between the sexes.

Candidal thrombophlebitis of central veins: case report and review.

Although candidemia and central catheter septic thrombosis is quite common, central veins thrombophlebitis caused by Candida spp. is a rarely reported complication in critically ill patients. Here we report a case of thrombophlebitis of the right internal jugular and subclavian veins due to Candida albicans which occurred in a patient admitted in the intensive care unit for major trauma. The individual was eventually cured after prolonged course of antifungal therapy. We also review 24 additional cases of Candida induced central veins thrombophlebitis reported since 1978. A central vein catheter was in place in all 25 patients with 21 (84%) being admitted in an intensive care unit, 22 (88%) were receiving total parenteral nutrition and 23 (92%) undergoing a course of antibiotic therapy. Overall mortality was 16%, including two patients who received no therapy and died. In the group of patients receiving only medical therapy, the mortality rate was 13%, while no deaths were observed among those treated with combined medical and surgical therapy. Literature data suggest that Candida caused central veins thrombophlebitis is a rare and probably underdiagnosed infectious complication of the critically ill patient. Despite the dramatic presentation with persistent candidemia, mortality is low even with a conservative medical approach with prolonged fungicidal therapy through the use of amphotericin B or echinocandins. Thus, the decision for a combined surgical debridement should be assessed for each patient.

Mortalidad y carga de muertes prematuras por flebitis y tromboflebitis, Cuba años 2000 y 2005 / Mortality and burden of premature deaths from phlebitis and thrombophlebitis in Cuba in the years 2000 and 2005

La flebitis y tromboflebitis de los miembros inferiores es una de las causas básicas de muerte por enfermedades vasculares periféricas y uno de los principales motivos de ingreso en los servicios de angiología del país. Identificar la mortalidad y la carga por muertes prematuras a consecuencia de la flebitis y tromboflebitis en la población cubana. Se realizó un estudio descriptivo retrospectivo de la mortalidad por flebitis y tromboflebitis en miembros inferiores en los años 2000 y 2005 según la base de datos de la Dirección Nacional de Estadística. Se realizó el cálculo de las tasas brutas y específicas de mortalidad por edad, sexo y la tasa de años de vida potenciales perdidos por muertes prematuras según sexo y provincias. La mayor tasa de mortalidad y de años de vida potenciales perdidos fue en el año 2005, en el grupo de edad de 60 años y más y en el sexo femenino. Incrementaron la carga por muertes prematuras las provincias de Ciego de Ávila, Camagüey, Villa Clara, Cienfuegos, Santiago de Cuba, Pinar del Río, Matanzas, Isla de la Juventud y Ciudad de La Habana. Estos resultados ofrecen una visión más amplia del impacto de la trombosis venosa en los miembros inferiores sobre el patrón de mortalidad del país. La carga por muertes prematuras constituye un elemento más, para planificar e implementar las políticas de salud relativas a las enfermedades venosas de los miembros inferiores.

Phlebitis and thrombophlebitis of the lower extremities is one of the basic causes of death from peripheral vascular diseases and one of the main reasons for admission to the Angiology Services throughout the country. Objectives To identify mortality rates and burden of premature deaths from phlebitis and thrombophlebitis occurred in the Cuban population. A retrospective descriptive study of mortality from phlebitis and thrombophlebitis of lower extremities in Cuba in the years 2000 and 2005 was conducted, taking data from the National Division of Statistics as a basis. Gross and specific mortality rates by sex and age, and the rate of potential lost years of life caused by premature deaths by sex and province were estimated. The highest mortality rate and potential lost years of life rate were found in the over 60 years-old group and the female sex in the year 2005. The burden of premature deaths increased in Ciego de Avila, Camaguey, Villa Clara, Cienfuegos, Santiago de Cuba, Pínar del Río, Matanzas, Isla de la Juventud and Ciudad de la Habana provinces. These results provide a broader overview of the impact of venous thrombosis on the lower limbs according to the national mortality patterns. The burden of premature deaths is another element for the planning and implementation of health policies related to venous diseases in the lower extremities.

Mortalidad y carga de muertes prematuras por flebitis y tromboflebitis, Cuba años 2000 y 2005 / Mortality and burden of premature deaths from phlebitis and thrombophlebitis in Cuba in the years 2000 and 2005

La flebitis y tromboflebitis de los miembros inferiores es una de las causas básicas de muerte por enfermedades vasculares periféricas y uno de los principales motivos de ingreso en los servicios de angiología del país. Identificar la mortalidad y la carga por muertes prematuras a consecuencia de la flebitis y tromboflebitis en la población cubana. Se realizó un estudio descriptivo retrospectivo de la mortalidad por flebitis y tromboflebitis en miembros inferiores en los años 2000 y 2005 según la base de datos de la Dirección Nacional de Estadística. Se realizó el cálculo de las tasas brutas y específicas de mortalidad por edad, sexo y la tasa de años de vida potenciales perdidos por muertes prematuras según sexo y provincias. La mayor tasa de mortalidad y de años de vida potenciales perdidos fue en el año 2005, en el grupo de edad de 60 años y más y en el sexo femenino. Incrementaron la carga por muertes prematuras las provincias de Ciego de Ávila, Camagüey, Villa Clara, Cienfuegos, Santiago de Cuba, Pinar del Río, Matanzas, Isla de la Juventud y Ciudad de La Habana. Estos resultados ofrecen una visión más amplia del impacto de la trombosis venosa en los miembros inferiores sobre el patrón de mortalidad del país. La carga por muertes prematuras constituye un elemento más, para planificar e implementar las políticas de salud relativas a las enfermedades venosas de los miembros inferiores(AU)

Phlebitis and thrombophlebitis of the lower extremities is one of the basic causes of death from peripheral vascular diseases and one of the main reasons for admission to the Angiology Services throughout the country. Objectives To identify mortality rates and burden of premature deaths from phlebitis and thrombophlebitis occurred in the Cuban population. A retrospective descriptive study of mortality from phlebitis and thrombophlebitis of lower extremities in Cuba in the years 2000 and 2005 was conducted, taking data from the National Division of Statistics as a basis. Gross and specific mortality rates by sex and age, and the rate of potential lost years of life caused by premature deaths by sex and province were estimated. The highest mortality rate and potential lost years of life rate were found in the over 60 years-old group and the female sex in the year 2005. The burden of premature deaths increased in Ciego de Avila, Camaguey, Villa Clara, Cienfuegos, Santiago de Cuba, Pínar del Río, Matanzas, Isla de la Juventud and Ciudad de la Habana provinces. These results provide a broader overview of the impact of venous thrombosis on the lower limbs according to the national mortality patterns. The burden of premature deaths is another element for the planning and implementation of health policies related to venous diseases in the lower extremities(AU)

[Acute-phase reactants and markers of inflammation in venous thromboembolic disease: correlation with clinical and evolution parameters]. / Reactantes de fase aguda y marcadores de inflamación en pacientes con enfermedad tromboembólica venosa: correlación con parámetros clínicos y evolutivos.

OBJECTIVE: To asses the association of acute reactants and interleukin 6 and 8 (IL-6 & IL-8) at diagnosis of venous thromboembolic disease (VTD) and clinical outcome. METHODS: 100 patients were diagnosed of VTD by image tests. Acute reactants (C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen), D-dimer and IL-6 and IL-8 we measured at the moment of diagnosis. We made a 12 month follow-up of these patients to notice any clinical evolution outcomes (recurrences, bleeding, post-phlebitic syndrome, death). RESULTS: IL-6 was increased in 9 patients and IL-8 in 3. The risk factors, time to diagnosis and pulmonary embolism rate were similar in both interleukin groups (normal and high levels). Fibrinogen levels were significantly increased in high IL-6 group (585 +/- 179 vs. 485 +/- 154 mgr/dl; p = 0.05). During follow-up there were 5 deaths, 3 recurrences, 11 bleedings and 43 postphlebitic syndromes. Normal ESR level was associated to postphlebitic syndrome (17.8 +/- 14.5 vs. 31.4 +/- 27.4 mm/1st h; p = 0.016). Patients who had high levels of IL-6 had worse survival than these with normal levels (p = 0.015). CONCLUSION: IL-6, ESR, and CPR at diagnosis of VTD could be useful to identified patients with higher risks of death and postphlebitic syndrome during the first year after diagnosis.

Reactantes de fase aguda y marcadores de inflamación en pacientes con enfermedad tromboembólica venosa: correlación con parámetros clínicos y evolutivos / Acute reactives and markers of inflammation in venous thromboembolic disease: clinical and evolution outcomes

Objetivo: Determinar si los reactantes de fase aguda, dímero D y las interleucinas 6 y 8 (IL-6 e IL-8) en el momento de diagnóstico de la enfermedad tromboembólica venosa (ETEV) se relacionan con alguna variable clínica y evolutiva relevante. Material y métodos: Se estudiaron 100 pacientes con el diagnóstico de ETEV por pruebas de imagen. Se determinaron reactantes de fase aguda (proteína C reactiva (PCR), velocidad de sedimentación globular (VSG) y fibrinógeno), dímero D así como IL-6 e IL-8 en el momento del diagnóstico. Se recogieron los eventos clínicos más relevantes (recurrencia, hemorragia, síndrome postflebítico y mortalidad) durante un período de seguimiento de 12 meses. Resultados: La IL-6 estaba elevada en 9 pacientes y la IL-8 en 3. Los factores de riesgo, la duración de los síntomas y la forma de presentación como embolismo pulmonar fueron similares entre los dos grupos. Los niveles de fibrinógeno estaban significativamente aumentados (585 ±179 vs. 485 ± 154 mg/dl; p = 0,05) en el grupo de pacientes con IL-6 elevada. En los 12 meses de seguimiento la frecuencia de fallecimientos, recurrencias, hemorragias y síndrome postflebítico fueron 5, 3, 11 y 43, respectivamente. La VSG normal se asoció de forma significativa a la aparición de síndrome postflebítico (17,8 ± 14,5 vs. 31,4 ± 27,4 mm/1ª h;p = 0,016). La supervivencia de los pacientes con cifras elevadas de IL-6 fue significativamente peor que la del resto de los pacientes (p = 0,015). Conclusiones: Niveles elevados de IL-6 y los reactantes de fase aguda (VSG y PCR) en el momento del diagnóstico de la ETEV podrían servirpara identificar a los pacientes con mayor mortalidad y mayor probabilidad de desarrollar un síndrome postflebítico durante el primer año

Objective: To assess the association of acute reactants and interleukin 6 and 8 (IL-6 & IL-8) at diagnosis of venous thromboembolic disease (VTD) and clinical outcome. Methods: 100 patients were diagnosed of VTD by image tests. Acute reactants (C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen), D-dimer and IL-6 and IL-8 we measured at the moment of diagnosis. We made a 12 month follow-up of these patients to notice any clinical evolution outcomes (recurrences, bledding, postphlebitic syndrome, death). Results: IL-6 was increased in 9 patients and IL-8 in 3. The risk factors, time to diagnosis and pulmonary embolism rate were similar in both interleukin groups (normal and high levels). Fibrinogen levels were significantly increased in high IL-6 group (585 ± 179 vs. 485 ± 154 mgr/dl; p=0.05). During follow-up there were 5 deaths, 3 recurrences, 11 bleedings and 43 postphlebitic syndromes. Normal ESR level was associated to postphlebitic syndrome (17.8 ± 14.5 vs. 31.4 ± 27.4 mm/1st ;;h; p=0.016). Patients who had high levels of IL-6 had worse survival than these with normal levels (p = 0.015). Conclusion: IL-6, ESR, and CPR at diagnosis of VTD could be useful to identified patients with higher risks of death and postphlebitic syndrome during the first year after diagnosis

[Treatment of thrombosis with low-molecular-weight heparin. Comparison of body weight-adjusted and fixed dosage]. / Thrombosetherapie mit niedermolekularem HeparinVergleich von körpergewichtsadjustierter mit fixer Dosierung.

BACKGROUND: The treatment of deep vein thrombosis (DVT) has been simplified and become safer after introduction of low-molecular-weight heparin (LMWH). The dosage of LMWH was performed by body weight adjustment without dose-finding studies. DATA: In three large clinical trials, the improved efficacy and safety of body weight-independent fixed-dose LMWH Certoparin were demonstrated using 2 x 8,000 IU subcutaneously per day for the initial treatment of symptomatic acute DVT. The reduction of thrombus size after 14 days, determined with the Marder score, and the combined endpoint, consisting of recurrent thromboembolism, major bleeding and mortality, was lower over the initial treatment with LMWH compared to intravenous APTT-adjusted unfractionated heparin (UFH). The benefit of the clinical endpoints over 6 months was demonstrated in two clinical trials. CONCLUSION: Treatment of acute DVT is more effective and safer using fixeddose 2 x 8,000 IU Certoparin for the initial treatment compared to UFH.

Simultaneous bilateral, staged bilateral, and unilateral total knee arthroplasty. A survival analysis.

BACKGROUND: The rates of perioperative morbidity and mortality are areas of concern associated with simultaneous bilateral total knee replacement. The purpose of this paper was to compare the rates of morbidity and mortality and the clinical outcome in large groups of consecutive patients undergoing simultaneous bilateral total knee replacement, unilateral total knee replacement, or staged bilateral total knee replacement. METHODS: A total of 6200 total knee replacements, performed in 3998 patients between 1983 and 2000, consisted of 2050 simultaneous bilateral, 1796 unilateral, and 152 staged bilateral total knee replacements. A review of each group was conducted to compare the rates of morbidity and mortality, the survival of the prosthesis, and the clinical outcome. Kaplan-Meier survival analyses were performed with failure defined as revision because of aseptic loosening and as patient death. Complications and Knee Society scores were compared throughout the fifteen-year follow-up period (average, 4.3 years of follow-up). RESULTS: The unilateral group had significantly lower Knee Society scores than the simultaneous bilateral group (p < 0.0001 up to twelve years, and p = 0.0067 at fifteen years) across all postoperative time-intervals. The percentage of patients who had thrombophlebitis was significantly higher in the simultaneous bilateral group (0.9%) than in the unilateral group (0.3%) (p = 0.0326). No significant differences were found with regard to prosthetic failure, cardiac complications, and the rates of death in the three groups. Ten years postoperatively, the simultaneous bilateral group had a significantly higher rate of patient survival than did the unilateral group (78.6% compared with 72.0%) (p = 0.0062). CONCLUSIONS: The significantly higher rate of thrombophlebitis in the simultaneous bilateral group compared with that in the unilateral group may represent a greater risk to those patients. However, we believe that when there are adequate indications for bilateral total knee replacement, simultaneous bilateral arthroplasty is beneficial to patients, with a minimal increase in the risk of death or other complications compared with that associated with unilateral and staged procedures.

Recurrent thromboembolism in patients with vena cava filters.

BACKGROUND: Patients with venous thromboembolic disease are treated with anticoagulation or vena cava filter placement to prevent pulmonary embolism. A recent report suggested that filter placement may increase the risk of recurrent deep venous thrombosis (DVT) and prompted a review of our experience. METHODS: Prospectively collected data on 2109 consecutive patients receiving filters were evaluated for recurrent thromboembolism, vena cava occlusion, or venous stasis ulceration. Outcomes were stratified and analyzed according to the use of anticoagulants at the time of insertion and at follow-up. Incidence rates were also compared with reports in the literature. RESULTS: Of 1191 patients with DVT at filter placement, complete follow-up data at a mean of 9 years were available for 465. Recurrent DVT was found in 12% of the 241 patients who were given anticoagulants and 15% of the 224 who were not (P >.05). We also failed to find a significant association between the use of anticoagulation and the incidence of pulmonary embolism (2%), stasis ulceration (2%), and vena cava occlusion (0.0). CONCLUSIONS: Recurrent DVT in patients with existing thromboembolic disease is not an unexpected event, which, in our experience, is not associated with anticoagulant or filter use. Anticoagulation should be used when possible to treat existing DVT to reduce thrombus progression and potentially to reduce subsequent complications but does not seem to reduce the rate of recurrent DVT. Rates of recurrent thromboembolism were consistently less than the 20% to 50% reported in the literature.

Clinically suspected pulmonary embolism: is it safe to withhold anticoagulation after a negative spiral CT?

The goal of this study was 3-month clinical outcome in nonanticoagulated patients with clinically suspected acute pulmonary embolism (PE) following a negative spiral CT. During a 6-month period 305 patients underwent spiral CT, of whom only 8 also had a lung scintigraphy. In patients with a final CT report read as not positive for acute PE, all hospital records and answers to a patient questionnaire were analyzed for episodes of venous thrombembolism (VTE). Acute PE was diagnosed at spiral CT in 61 patients (20%). Twenty-six of the remaining 244 patients were excluded from further analysis because of (a) long-term anticoagulation due to symptomatic acute deep venous thrombosis (n = 5), clinically diagnosed acute PE (n = 2), chronic recurrent VTE (n = 4), and cardiac disorders (n = 5); and (b) a normal perfusion scintigram (n = 4) or a negative pulmonary arteriogram (n = 6). Three patients were lost to follow-up. Among the remaining 215 patients only 10 had undergone a negative lower extremity venous study. Sixteen patients (7%) died during the follow-up period, 6 of whom underwent autopsy. Venous thrombembolism was diagnosed in three of the 215 patients (1.4%, 95% confidence limits: 0.5-4.0%), one causing the patient's death. Two patients had advanced thoracic malignancies and the third severe chronic obstructive pulmonary disease (84 years old). A negative spiral CT may be able to exclude clinically significant acute PE with the same accuracy as a normal lung scintigraphy or a negative pulmonary arteriography.

Low molecular weight heparin versus oral anticoagulants in the long-term treatment of deep venous thrombosis.

PURPOSE: The purpose of this study was to evaluate whether low molecular weight heparin (LMWH) could be equal or more effective than conventional oral anticoagulants (OAs) in the long-term treatment of deep venous thrombosis (DVT). METHODS: One hundred fifty-eight patients with symptomatic DVT of the lower limbs confirmed by means of duplex ultrasound scan were randomized to receive 3 to 6 months' treatment with nadroparine calcium or acenocoumarol. Quantitative and qualitative duplex scan scoring systems were used to study the evolution of thrombosis in both groups at 1, 3, 6, and 12 months. RESULTS: During the 12-month surveillance period, two (2.5%) of the 81 patients who received LMWH and seven (9%) of the 77 patients who received OAs had recurrence of venous thrombosis (not significant). In the LMWH group no cases of major bleeding were found, and four cases (5.2%) occurred in the OA group (not significant). The mortality rate was nine (11.1%) in the LMWH group and 7.8% in the OA group (not significant). The quantitative mean duplex scan score decreased in both groups during the follow-up and had statistical significance after long-term LMWH treatment on iliofemoral DVT (1, 3, 6, and 12 months), femoropopliteal DVT (1-3 months), and infrapopliteal DVT (first month). Duplex scan evaluation showed that the rate of venous recanalization significantly increased in the common femoral vein at 6 and at 12 months and during each point of follow-up in the superficial and popliteal veins in the LMWH group. Reflux was significantly less frequent in communicating veins after LMWH treatment (17.9% vs 32.2% in the OA group). The reflux rates in the superficial (22.4% in the LMWH group, 30.6% in OA group) and deep (13.4% vs 17.7%) venous system showed no significant differences between groups. CONCLUSIONS: The unmonitored subcutaneous administration of nadroparine in fixed daily doses was more effective than oral acenocoumarol with laboratory control adjustment in achieving recanalization of leg thrombi. With nadroparine, there was less late valvular communicating vein insufficiency, and it was at least as efficacious and safe as oral anticoagulants after long-term administration. These results suggest that LMWHs may therefore represent a real therapeutic advance in the long-term management of DVT.

Prophylactic vena caval filters in trauma: the rest of the story.

OBJECTIVE: The purpose of this study was to describe outcomes for patients with trauma who had vena caval filters placed in the absence of venous thromboembolic disease (group P) and compare them with outcomes for patients with trauma who had filters placed after either deep venous thrombosis or pulmonary embolism (group T). DESIGN: The study is a case series of consecutive patients who received vena caval filters after traumatic injury. Data were collected prospectively at the time of filter placement from reports of diagnostic studies obtained for clinical indications and during the annual follow-up examinations. Event rate findings are based on objective tests. Data were obtained from the Michigan Vena Cava Filter Registry. RESULTS: Filters were placed in 385 patients with trauma; 249 of these filters were prophylactic (group P). Event rates were similar in the two groups. New pulmonary embolism was diagnosed in 1.5% of the patients in group P and 2% of the patients in group T. Caval occlusion rates were 3.5% for group P and 2.3% for group T. In all, 15.6% of the patients in group P had deep venous thrombosis or pulmonary embolism after placement. The frequencies of lower extremity swelling and use of support hose were higher in group T than in group P (43% vs 25% and 25% vs 3.5%, respectively; P <.005). Outcomes were comparable in the two groups with respect to mechanical stability of the filter. CONCLUSIONS: The prophylactic indication for vena caval filter placement in patients with trauma is associated with a low incidence of adverse outcomes while providing protection from fatal pulmonary embolism. The current challenge is to limit the number of unnecessary placements through improved methods of risk stratification.

Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial.

BACKGROUND: Previous trials of antiplatelet therapy for the prevention of venous thromboembolism have individually been inconclusive, but a meta-analysis of their results indicated reductions in the risks of deep-vein thrombosis and of pulmonary embolism in various high-risk groups. The aim of this large randomised placebo-controlled trial was to confirm or refute these apparent benefits. METHODS: During 1992-1998, 148 hospitals in Australia, New Zealand, South Africa, Sweden and the UK randomised 13,356 patients undergoing surgery for hip fracture, and 22 hospitals in New Zealand randomised a further 4088 patients undergoing elective arthroplasty. Study treatment was 160 mg daily aspirin or placebo, started preoperatively and continued for 35 days. Patients received any other thromboprophylaxis thought necessary. Follow-up was of mortality and of in-hospital morbidity up to day 35. FINDINGS: Among the patients with hip fracture, allocation to aspirin produced proportional reductions in pulmonary embolism of 43% (95% CI 18-60; p=0.002) and in symptomatic deep-vein thrombosis of 29% (3-48; p=0.03). Pulmonary embolism or deep-vein thrombosis was confirmed in 105 (1.6%) of 6679 patients assigned aspirin compared with 165 (2.5%) of 6677 assigned placebo, which represents an absolute reduction of 9 (SE 2) per 1000 and a proportional reduction of 36% (19-50; p=0.0003). Similar proportional effects were seen in all major subgroups, including patients receiving subcutaneous heparin. Aspirin prevented 4 (1) fatal pulmonary emboli per 1000 patients (18 aspirin-group vs 43 placebo-group deaths), representing a proportional reduction of 58% (27-76; p=0.002), with no apparent effect on deaths from any other vascular cause (hazard ratio 1.04 [95% CI 0.86-1.26]) or non-vascular cause (1.01 [0.84-1.23]). Deaths due to bleeding were few (13 aspirin vs 15 placebo), but there was an excess of 6 (3) postoperative transfused bleeding episodes per 1000 patients assigned aspirin (p=0.04). Among elective-arthroplasty patients, rates of venous thromboembolism were lower, but the proportional effects of aspirin were compatible with those among patients with hip fracture. INTERPRETATION: These results, along with those of the previous meta-analysis, show that aspirin reduces the risk of pulmonary embolism and deep-vein thrombosis by at least a third throughout a period of increased risk. Hence, there is now good evidence for considering aspirin routinely in a wide range of surgical and medical groups at high risk of venous thromboembolism.

[The concept of ambulatory therapy of proximal deep venous thrombosis]. / Das Konzept der ambulanten Therapie der proximalen tiefen Venenthrombose.

In recent studies outpatient treatment of proximal deep venous thrombosis with low-weight-molecular heparin is shown as safe and effective as the treatment within the hospital. The incidence of recurrent thromboembolism, major bleeding and mortality is not higher in an ambulatory setting than in the hospital. The comfort of the patient is higher, the costs can be reduced. The present review discusses the different conditions for ambulatory treatment of deep venous thrombosis. The question will be addressed which patients will probably be considered for outpatient treatment of deep vein thrombosis.

Long-term clinical follow-up in 265 patients with deep venous thrombosis initially treated with either unfractionated heparin or dalteparin: a retrospective analysis.

The primary objective of this retrospective study was to describe the frequency of a post-thrombotic syndrome in 265 patients previously treated for deep venous thrombosis (DVT). The secondary objectives were to document the frequency of recurrent venous thromboembolism (VTE) and mortality, especially from malignant disease. The patients were evaluated 5-14 years after inclusion in three randomized trials comparing continuous intravenous (i.v.) infusion of unfractionated heparin (UFH) (n = 85) with a low molecular weight heparin (LMWH), dalteparin (n = 180). The median post-thrombotic score at follow-up was 2 (range 0-8). In a multiple step-wise regression analysis the postthrombotic score was significantly higher among patients with initial proximal DVT (p = 0.0001) as compared with those who had distal DVT. A recurrent venous thromboembolic event was diagnosed in 29.4% of the patients treated with dalteparin and in 23.5% of the patients treated with UFH (ns). A secondary risk factor for venous thromboembolism and a longer duration of treatment with oral anticoagulants (OAC) were significantly associated with a lower risk for recurrent VTE, whereas malignant disease diagnosed during follow-up was associated with a higher risk. During follow-up a total of 40.7% of patients had died. No difference in total mortality or mortality from malignant disease was demonstrated between the two drugs. In conclusion, a severe post-thrombotic syndrome occured relatively infrequent. considering the long observation period. Proximal DVT was significantly associated with a more severe post-thrombotic syndrome. After 14 years follow-up, no significant differences were observed in overall mortality, mortality from malignant disease or recurrent VTE between UFH- and dalteparin-treated patients. Malignant disease was a risk factor for recurrent VTE, the presence of a secondary risk factor and a longer duration of treatment with OAC decreased the risk for recurrent VTE.

Heparin and low molecular weight heparin for treatment of acute pulmonary embolism.

Pulmonary embolism occurs in more than 175,000 patients each year in the United States. The objectives of treatment are to prevent death from the existing embolus, to prevent death and morbidity from recurrent pulmonary embolism, and to prevent morbidity from recurrent deep-vein thrombosis. For patients with adequate cardiorespiratory reserve, the primary objective is to prevent recurrent pulmonary embolism. Anticoagulant therapy with intravenous unfractionated heparin or subcutaneous low molecular weight heparin followed by oral anticoagulant treatment for at least 3 months is the treatment of choice for most of these patients. Clinical trials indicate that the effectiveness of intravenous heparin depends on achieving an adequate heparin effect (activated partial thromboplastin time above lower limit) during the initial 24 hours. A validated protocol for intravenous heparin should be used to lessen the likelihood of delayed heparinization. Low molecular weight heparin given subcutaneously either once or twice daily is as effective as intravenous heparin for the treatment of patients with deep-vein thrombosis and submassive pulmonary embolism. Low molecular weight heparin enables many patients with uncomplicated deep-vein thrombosis to be treated in an outpatient setting.