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2.
Thromb Res ; 191: 9-14, 2020 Apr 23.
Artigo em Inglês | MEDLINE | ID: mdl-32353746

RESUMO

BACKGROUND: Few data are available on the rate and characteristics of thromboembolic complications in hospitalized patients with COVID-19. METHODS: We studied consecutive symptomatic patients with laboratory-proven COVID-19 admitted to a university hospital in Milan, Italy (13.02.2020-10.04.2020). The primary outcome was any thromboembolic complication, including venous thromboembolism (VTE), ischemic stroke, and acute coronary syndrome (ACS)/myocardial infarction (MI). Secondary outcome was overt disseminated intravascular coagulation (DIC). RESULTS: We included 388 patients (median age 66 years, 68% men, 16% requiring intensive care [ICU]). Thromboprophylaxis was used in 100% of ICU patients and 75% of those on the general ward. Thromboembolic events occurred in 28 (7.7% of closed cases; 95%CI 5.4%-11.0%), corresponding to a cumulative rate of 21% (27.6% ICU, 6.6% general ward). Half of the thromboembolic events were diagnosed within 24 h of hospital admission. Forty-four patients underwent VTE imaging tests and VTE was confirmed in 16 (36%). Computed tomography pulmonary angiography (CTPA) was performed in 30 patients, corresponding to 7.7% of total, and pulmonary embolism was confirmed in 10 (33% of CTPA). The rate of ischemic stroke and ACS/MI was 2.5% and 1.1%, respectively. Overt DIC was present in 8 (2.2%) patients. CONCLUSIONS: The high number of arterial and, in particular, venous thromboembolic events diagnosed within 24 h of admission and the high rate of positive VTE imaging tests among the few COVID-19 patients tested suggest that there is an urgent need to improve specific VTE diagnostic strategies and investigate the efficacy and safety of thromboprophylaxis in ambulatory COVID-19 patients.

3.
Vasa ; : 1-8, 2020 Apr 06.
Artigo em Inglês | MEDLINE | ID: mdl-32248759

RESUMO

Background: Physical attributes of conventional stents used in the ilio-caval territory are often unfavorable in the presence of external compression close to the bifurcation. A hybrid oblique stent was developed for the treatment of common iliac vein compression without compromising the contralateral iliac vein inflow. Patients and methods: The ongoing international monitored TOPOS study enrolled 60 patients with post-thrombotic syndrome (PTS) treated with the sinus-Obliquus stent (optimed) and provisional distal stent extension. At 3-month follow-up, patency rates were obtained from duplex ultrasound, and clinical outcomes were assessed by the Villalta score, revised venous severity score (rVCSS), pain intensity score and chronic venous disease quality of life questionnaire (CIVIQ-20). Results: Mean age was 46.6 ± 14.9 years (68.3 % women). Mean number of implanted stents was 1.9 ± 0.6; 12 (20 %) patients received the hybrid oblique stent only. Forty-eight (80 %) patients had distal stent extension, and 42 (70 %) had stents below the inguinal ligament. Four (7 %) patients (all with stent extension) developed stent thrombosis. Primary and secondary patency rates at 3 months were 93.1 % (95 %CI 83.3-98.1 %), and 100 % (95 %CI 93.8-100 %), respectively. Improvement in Villalta, rVCSS, CIVIQ-20, and pain intensity score from baseline to 3-month follow-up was 6.9 ± 1.4 points (95 %CI 4.1-9.8; p < 0.0001), 3.4 ± 1.0 points (95 %CI 1.3-5.4 points; p < 0.01), 13.6 ± 2.7 points (95 %CI 8.2-19.0 points; p < 0.0001), and 2.4 ± 0.5 (95 %CI 1.4-3.3; p < 0.0001), respectively. At follow-up, 38 (63 %) patients were free from the PTS and none developed contralateral deep vein thrombosis. Conclusions: In patients with PTS and common iliac vein compression, treatment with the hybrid oblique stent with provisional stent extension resulted in high patency rates and improvement in PTS severity and quality of life at 3-month. Two-year results of TOPOS will assess the durability of this treatment.

4.
Sci Rep ; 10(1): 2495, 2020 Feb 12.
Artigo em Inglês | MEDLINE | ID: mdl-32051462

RESUMO

The association of glycated hemoglobin (HbA1c) with venous thromboembolism (VTE) and death in the elderly is unknown. In the SWEETCO 65+ study we analyzed prospectively a Swiss Cohort of Elderly Patients with Venous Thromboembolism (SWITCO 65+). 888 patients were enrolled for the SWEETCO 65+ analysis. HbA1c was determined at baseline and divided into three categories (HbA1c < 5.7%, normal range; 5.7-6.49%, pre-diabetic range; and >6.5%, diabetic range). Median follow-up was 2.5 years. The primary endpoint was recurrent VTE. Secondary endpoints included all-cause mortality and major bleeds. The total prevalence of diabetes was 22.1%. The risk of recurrent VTE was similar in patients with HbA1c with pre-diabetes (adjusted subhazard ratio (aSHR) 1.07 [0.70 to 1.63]) and diabetes (aSHR 0.73 [0.39 to 1.37]) as compared to those with a HbA1c in the normal range. However, a HbA1c ≥ 6.5% (median IQ range 7.0 [6.70;7.60]) was significantly associated with a higher risk of all-cause mortality (adjusted hazard ratio [aHR] 1.83 [1.21 to 2.75]). In summary we found no association between HbA1c and major bleeding. Elevated HbA1c levels are not associated with recurrent VTE but with increased all-cause mortality in an elderly population with acute VTE.

6.
Semin Thromb Hemost ; 45(8): 851-858, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31622993

RESUMO

Renal impairment (RI) has increased substantially over the last decades. In the absence of data from confirmatory research, real-life data on anticoagulation treatment and clinical outcomes of venous thromboembolism (VTE) in patients with RI are needed. In the SWIss Venous ThromboEmbolism Registry (SWIVTER), 2,062 consecutive patients with objectively confirmed VTE were enrolled. In the present analysis, we compared characteristics, initial and maintenance anticoagulation, and adjusted 90-day clinical outcomes of those with (defined as estimated creatinine clearance < 30 mL/min) and without severe RI. Overall, 240 (12%) patients had severe RI; they were older, and more frequently had chronic and acute comorbidities. VTE severity was similar between patients with and without severe RI. Initial anticoagulation in patients with severe RI was more often performed with unfractionated heparin (44 vs. 24%), and less often with low-molecular-weight heparin (LMWH) (52 vs. 61%) and direct oral anticoagulants (DOACs; 4 vs. 12%). Maintenance anticoagulation in patients with severe RI was more frequently managed with vitamin K antagonists (70 vs. 60%) and less frequently with DOAC (12 vs. 21%). Severe RI was associated with increased risk of 90-day mortality (9.2 vs. 4.2%, hazard ratio [HR]: 2.27, 95% confidence interval [CI]: 1.41-3.65), but with similar risk of recurrent VTE (3.3 vs. 2.8%, HR: 1.19, 95% CI: 0.57-2.52) and major bleeding (2.1 vs. 2.0%, HR: 1.05, 95% CI: 0.41-2.68). In patients with severe RI, the use of LMWH versus any other treatment was associated with reduced mortality (HR: 0.37; 95% CI: 0.14-0.94; p = 0.036) and similar rate of major bleeding (HR: 0.59, 95% CI: 0.17-2.00; p = 0.39). Acute or chronic comorbidities rather than VTE severity or recurrence may explain increased early mortality in patients with severe RI. The higher rate of VTE recurrence, specifically fatal events, than major bleeding reinforces the need for effective anticoagulation in VTE patients with severe RI.

7.
Thromb Haemost ; 119(12): 2064-2073, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31659739

RESUMO

BACKGROUND: Patients with postthrombotic syndrome (PTS) treated with stents are at risk of stent thrombosis (ST). The incidence of ST in the presence and absence of anticoagulation therapy (AT) is unknown. Risk factors are not well understood. PATIENTS AND METHODS: From the prospective Swiss Venous Stent registry, we conducted a subgroup analysis of 136 consecutive patients with PTS. Incidence of ST was estimated from duplex ultrasound or venography, and reported for the time on and off AT. Baseline, procedural, and follow-up data were evaluated to identify factors associated with ST. RESULTS: Median follow-up was 20 (interquartile range [IQR] 9-40) months. AT was stopped in 43 (32%) patients after 12 (IQR 6-14) months. Cumulative incidence of ST was 13.7% (95% confidence interval [CI] 7.8-19.6%) and 21.2% (95% CI 13.2-29.2%) during the first 6 and 36 months, respectively. The time-adjusted incidence rate was 11.2 (95% CI 7.7-16.2) events per 100 patient-years, 11.3 (95% CI 7.3-17.3) for the period on, and 11.2 (95% CI 5.3-23.6) for the period off AT. May-Thurner syndrome (MTS) was associated with decreased incidence of ST (hazard ratio [HR] 0.37, 95% CI 0.15-0.91), whereas age < 40 years (HR 2.26, 95% CI 1.03-4.94), stents below the common femoral vein (HR 3.03, 95% CI 1.28-7.19), and postthrombotic inflow veins (HR 2.92, 95% CI 1.36-6.25) were associated with increased incidence. CONCLUSION: The 6-month incidence of ST was considerably high. Beyond 6 months, consecutive annual incidence rates persisted at 4.1 and 3.4% per year thereafter. Patients with higher incidence of ST were younger, had stents below the common femoral vein, postthrombotic leg inflow veins, and less often MTS. Incidence rates for the period on and off AT must be interpreted with caution. CLINICAL TRIAL REGISTRATION: The study is registered on the National Institutes of Health Web site (ClinicalTrials.gov; identifier NCT02433054).

9.
Artigo em Inglês | MEDLINE | ID: mdl-31392312

RESUMO

INTRODUCTION: The role and selection of antithrombotic therapy to improve limb outcomes in chronic lower extremity artery disease (LEAD) is still debated. We conducted a meta-analysis to examine the efficacy and safety of anti-thrombotic and more intense antithrombotic therapy on limb outcomes and limb salvage in patients with chronic LEAD. METHODS: Study inclusion criteria were: enrollment of patients with LEAD, randomized allocation to more vs. less intense antithrombotic therapy [more vs. less intense single antiplatelet therapy (SAPT); dual antiplatelet therapy (DAPT) vs. SAPT; dual antithrombotic therapy vs. SAPT or oral anticoagulant]; enrolment of ≥ 200 patients; reporting of at least one of following outcomes: limb amputation or revascularization. Seven randomized studies enrolling 30'447 patients were included. RESULTS: Over a median follow-up of 24 months, more vs. less intense antithrombotic therapy or placebo significantly reduced the risk of limb revascularization (relative risk [RR]: 0.89; 95% confidence interval [CI]: 0.83 - 0.94) and limb amputation (RR: 0.63, 95% confidence interval [CI]: 0.46-0.86), as well as stroke (RR: 0.82, 95% CI: 0.70-0.97). There was no statistically significant effect on the risk of myocardial infarction (RR: 0.98, 95% CI: 0.87-1.11), all-cause (RR: 0.93, 95% CI: 0.86-1.01) and cardiovascular death (RR: 0.97, 95% CI: 0.86-1.08). Risk of major bleeding increased (RR: 1.23, 95% CI: 1.04-1.44). CONCLUSION: In patients with LEAD, more intense antithrombotic therapy reduces risk of limb amputation and revascularization as well as stroke, with an increase in the risk of bleeding events.

10.
Eur J Clin Invest ; 49(9): e13154, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31246275

RESUMO

BACKGROUND: Combining high-sensitivity cardiac Troponin T (hs-cTnT), NT-pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity C-reactive protein (hs-CRP) may improve risk stratification of patients with pulmonary embolism (PE) beyond the PESI risk score. METHODS: In the prospective multicentre SWITCO65+ study, we analysed 214 patients ≥ 65 years with a new submassive PE. Biomarkers and clinical information for the PESI risk score were ascertained within 1 day after diagnosis. Associations of hs-TnT, NT-proBNP, hs-CRP and the PESI risk score with the primary endpoint defined as 6-month mortality were assessed. The discriminative power of the PESI risk score and its combination with hs-cTnT, NT-proBNP and hs-CRP for 6-month mortality was compared using integrated discrimination improvement (IDI) index and net reclassification improvement (NRI). RESULTS: Compared with the lowest quartile, patients in the highest quartile had a higher risk of death during the first 6 months for hs-cTnT (adjusted HR 10.22; 95% CI 1.79-58.34; P = 0.009) and a trend for NT-proBNP (adjusted HR 4.3; 95% CI 0.9-20.41; P = 0.067) unlike hs-CRP (adjusted HR 1.97; 95% CI 0.48-8.05; P = 0.344). The PESI risk score (c-statistic 0.77 (95% CI 0.69-0.84) had the highest prognostic accuracy for 6-month mortality, outperforming hs-cTnT, NT-proBNP and hs-CRP (c-statistics of 0.72, 0.72, and 0.54), respectively. Combining all three biomarkers had no clinically relevant impact on risk stratification when added to the PESI risk score (IDI = 0.067; 95% CI 0.012-0.123; P = 0.018; NRI = 0.101 95% CI -0.099-0.302; P = 0.321). CONCLUSIONS: In elderly patients with PE, 6-month mortality can adequately be predicted by the PESI risk score alone.

11.
J Vasc Surg Cases Innov Tech ; 5(2): 169-173, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31193522

RESUMO

Acute superior vena cava (SVC) syndrome is managed by endovascular recanalization, venoplasty with stenting, and anticoagulation. It is often associated with central venous catheters. We present a case of a 55-year-old woman with acute SVC syndrome due to port-a-cath-associated thrombosis of the SVC and the brachiocephalic and subclavian veins who was treated with catheter-based thrombectomy and local spray thrombolysis, venoplasty, and stent placement. Port-a-cath restoration was achieved in the same session by endovascular snaring and repositioning. This case demonstrates that reoperation with surgical catheter removal and reinsertion of central venous catheters with possible complications (eg, rethrombosis, bleeding) can be avoided by single-session endovascular management.

12.
Thromb Haemost ; 119(7): 1094-1101, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31167251

RESUMO

There is a need to improve the efficacy and safety of catheter-directed thrombolysis (CDT) for thrombo-occlusive diseases, and ultrasound-assisted CDT (USAT) is a promising approach. We tested if thrombolysis efficacy of USAT can be improved by adding gaseous microbubbles (MB). We developed an in vitro dynamic overflow model for iliofemoral deep vein thrombosis, and added MB to an USAT system with ultrasound energy and dose of tissue plasminogen activator according to clinical practice. A total of 64 clots (mean baseline weight of 8.23 ± 1.12 g, generated from citrated human whole blood from 7 healthy male volunteers) were randomly assigned to 1 of 4 study protocols of 30 minutes' duration: negative control, CDT, USAT, and USAT + MB.Thrombolysis efficacy was assessed by measuring the change in D-dimer levels in the overflow liquid and the percentage of clot weight reduction. Compared to negative control, change in D-dimer increased by 62% (p = 0.017), 128% (p = 0.002), and 177% (p < 0.001) in the CDT, USAT, and USAT + MB groups, respectively. D-dimer increase was greater in the USAT than in the CDT group (p = 0.014), and greater in the USAT + MB than in the USAT group (p = 0.033). Compared to negative control, percentage of clot weight reduction increased by 123% (p = 0.016), 154% (p = 0.002), and 233% (p < 0.001) in the CDT, USAT, and USAT + MB groups, respectively. Percentage of clot weight reduction was greatest in the USAT + MB group (p < 0.05 compared with all other groups). In conclusion, our in vitro study suggests that the thrombolytic efficacy of USAT in human whole blood clots can be improved by local administration of MB.


Assuntos
Artéria Femoral/patologia , Fibrinolíticos/uso terapêutico , Terapia Trombolítica , Ultrassonografia de Intervenção/métodos , Trombose Venosa/tratamento farmacológico , Adulto , Cateteres , Artéria Femoral/diagnóstico por imagem , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Voluntários Saudáveis , Humanos , Masculino , Microbolhas , Ativador de Plasminogênio Tecidual/metabolismo , Resultado do Tratamento , Ondas Ultrassônicas
13.
Vasa ; 48(4): 331-339, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30667348

RESUMO

Background: The optimal duration of anticoagulation therapy (AT) following catheter-based therapy of acute iliofemoral deep vein thrombosis (IFDVT) with stent placement is unknown. Theoretically, resolving the underlying obstructive iliac vein lesion by a stent may eliminate the main trigger for recurrence, the post-thrombotic syndrome (PTS), and the need for extended-duration AT. Patients and methods: From 113 patients with acute IFDVT who underwent endovascular thrombus removal and stent placement, we compared patency rates and clinical outcomes between 58 patients on limited-duration AT (3-12 month) and 55 patients on extended-duration AT (> 12 months). Results: Mean follow-up duration was 26 ± 18 (range 3-77) months; it was 24 ± 18 (range 3-69) months after cessation of AT in the limited-duration AT group. In comparison to patients with extended-duration AT, patients with limited-duration AT were younger (38 versus 54 years; p < 0.001), more often female (74 % versus 49 %; p = 0.01), and had less often prior venous thromboembolism (VTE) (9 % versus 35 %; p = 0.001). May-Thurner syndrome was more frequent in the limited-duration AT group (66 % versus 38 %; p = 0.004). Overall, primary and secondary patency rates at 24 months were 80 % (95 % CI, 70-87 %) and 95 % (95 % CI, 88-98 %), respectively, with no difference between the groups. Overall, 17 (15 %) patients developed recurrent VTE, of which 14 (82 %) events were thrombotic stent occlusions, and 13 (76 %) events occurred during AT. In the limited-duration AT group, 98 % patients were free from the PTS at two years with a VTE recurrence rate of 3.5 per 100 patient years after cessation of AT. Conclusions: In selected patients with acute IFDVT and patent venous stent, particularly in younger and otherwise healthy patients with May-Thurner syndrome, it appears to be safe to discontinue AT 3-12 months after endovascular treatment. Clinical Trial Registration: The study is registered on the National Institutes of Health website (ClinicalTrials.gov; identifier NCT02433054).


Assuntos
Veia Femoral , Trombose Venosa , Adulto , Anticoagulantes , Feminino , Humanos , Veia Ilíaca , Pessoa de Meia-Idade , Stents , Terapia Trombolítica , Resultado do Tratamento , Trombose Venosa/terapia
14.
J Vasc Surg Venous Lymphat Disord ; 7(1): 122-125, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30385135

RESUMO

Catheter-directed thrombolysis for iliofemoral deep venous thrombosis (DVT) aims to reduce acute leg symptoms and to prevent the post-thrombotic syndrome. There are no data from controlled trials in pregnant patients. Reports of thrombolysis for treatment of DVT during pregnancy are scarce. Pregnancy is considered a relative contraindication to thrombolytic therapy because of the risk of bleeding and concerns about the effects of radiation exposure on the fetus. We report on a catheter-directed thrombolysis procedure without radiation and contrast medium exposure in a first-trimester pregnant patient with massive iliofemoral DVT and free-floating thrombus extending to the suprarenal inferior vena cava.

15.
J Thromb Haemost ; 17(2): 306-318, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30570809

RESUMO

Essentials Predictive ability of pro-hemostatic Gas6 for recurrent venous thromboembolism (VTE) is unknown. We measured Gas6 levels in 864 patients with VTE over 3 years. High Gas6 (> 157%) at diagnosis is associated with VTE recurrence, major bleeding and mortality. Gas6 plasma levels measured 12 months after the index VTE are discriminatory for VTE recurrence. SUMMARY: Background Growth arrest-specific gene 6 (Gas6) is a prohemostatic protein with an unknown predictive ability for recurrent venous thromboembolism (VTE). In the elderly, VTE results in higher mortality but does not have a higher rate of recurrence than in younger patients. Consequently, anticoagulation management in the elderly is challenging. Objective To prospectively investigate the performance of Gas6 in predicting VTE recurrence, major bleeding and mortality in the elderly. Methods Consecutive patients aged ≥ 65 years with acute VTE were followed for a period of 3 years. Primary outcomes were symptomatic VTE recurrence, major bleeding, and mortality. Plasma Gas6 was measured with ELISA. Results Gas6 levels were measured in 864 patients at the time of the index VTE (T1) and, in 70% of them, also 12 months later (T2). The Gas6 level at T1 was discriminatory for VTE recurrence (C-statistic, 0.56; 95% confidence interval [CI] 0.51-0.62), major bleeding (0.60, 95% CI 0.55-0.65) and mortality (0.69, 95% CI 0.65-0.73) up to 36 months. VTE recurrence up to 24 months after T2 was discriminated by the Gas6 level at T2 (0.62, 95% CI 0.54-0.71). High Gas6 levels (> 157%) and continuous Gas6 levels at T1 were associated with VTE recurrence up to 6 months and 12 months, respectively. Conclusions In elderly patients, a high Gas6 level is associated with higher risks of VTE recurrence, major bleeding, and death. These findings support further studies to assess the performance of Gas6 in adjusting the length of anticoagulation.

16.
Thromb Res ; 172: 86-93, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30391776

RESUMO

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).


Assuntos
Anticoagulantes/uso terapêutico , Procedimentos Endovasculares , Síndrome Pós-Trombótica/etiologia , Rivaroxabana/uso terapêutico , Terapia Trombolítica , Trombose Venosa/complicações , Trombose Venosa/terapia , Vitamina K/antagonistas & inibidores , Adulto , Idoso , Cateterismo/métodos , Procedimentos Endovasculares/métodos , Inibidores do Fator Xa/uso terapêutico , Feminino , Veia Femoral/patologia , Humanos , Veia Ilíaca/patologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Stents , Terapia Trombolítica/métodos , Resultado do Tratamento , Grau de Desobstrução Vascular/efeitos dos fármacos , Trombose Venosa/tratamento farmacológico , Trombose Venosa/patologia
17.
Hamostaseologie ; 38(2): 98-105, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29843174

RESUMO

Due to the manifold treatment options for the management of acute pulmonary embolism, state-of-the-art management requires risk stratification for choosing the adapted treatment for each patient. Reperfusion therapy is an integral part of therapy for patients with pulmonary embolism at high risk for mortality, but its role in patients with intermediate risk pulmonary embolism is more debated. The largest amount of evidence exists for systemic thrombolysis, which is an efficient therapy, but at the prize of an increased bleeding risk. In recent years, various types of catheter-based reperfusion therapies have been introduced, and evidence is growing that this therapy is as efficient as systemic thrombolysis, but with a more favourable safety profile. Surgical embolectomy remains a good alternative for unstable patients, especially for those with absolute contraindications for thrombolysis or after failed systemic thrombolysis. While the early benefits of reperfusion therapy are well documented, evidence for long-term benefit is still scarce. The scope of this review is to summarize the evidence for the currently available reperfusion therapies in the management of acute pulmonary embolism.


Assuntos
Embolectomia/métodos , Embolia Pulmonar/terapia , Reperfusão/métodos , Terapia Trombolítica/métodos , Doença Aguda , Cateteres , Gerenciamento Clínico , Humanos , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/cirurgia
18.
J Vasc Surg Venous Lymphat Disord ; 6(3): 312-320, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29550177

RESUMO

BACKGROUND: Occlusion of the inferior vena cava (IVC) often causes venous claudication, leg swelling, or skin changes. We hypothesized that the outcome of nitinol stents for endovascular reconstruction of the IVC is similar to the outcome reported for steel alloy stents. METHODS: From the prospective Bern Venous Stent Registry, we investigated technical success, patency rates, and clinical outcome in consecutive patients with endovascular IVC reconstruction. During routine follow-up visits, stent patency was assessed by duplex ultrasound. Clinical outcomes were evaluated using the Bozkaya score, Villalta score, and revised Venous Clinical Severity Score. RESULTS: Of the 62 patients (mean age, 46 ± 18 years), 33 (53%) patients were treated for the post-thrombotic syndrome, 17 (27%) for acute thrombosis, and 12 (19%) for nonthrombotic IVC occlusion. Technical success was achieved in 61 (98%) patients, with a mean of 4.5 ± 1.9 stents (iliac kissing stents in 84%). During follow-up (mean, 21 months), 22 (36%) underwent endovascular reintervention for symptomatic stent stenosis (13 [21%] with complete stent occlusion). Primary, primary assisted, and secondary patency rates at 24 months were 57% (95% confidence interval [CI], 50%-73%), 76% (95% CI, 65%-86%), and 87% (95% CI, 80%-95%), respectively. None developed new ulcers, and all eight patients with venous ulcers at baseline had complete healing. Twenty-nine (48%) patients showed significant clinical improvement, and another 26 (43%) were free from any symptoms or signs of venous hypertension. Patients with post-thrombotic venographic changes of the femoral veins at baseline or a history of thrombosis were more likely to lose primary patency compared with patients with normal leg inflow veins and no history of thrombosis (19 [48%] vs 3 [16%]; P = .02). CONCLUSIONS: The clinical outcome of endovascular reconstruction of the IVC with nitinol stents was favorable. However, approximately one-third of the patients required reintervention to maintain stent patency, most likely because of the impaired venous inflow.


Assuntos
Procedimentos Endovasculares/métodos , Stents Metálicos Autoexpansíveis , Veia Cava Inferior/cirurgia , Adulto , Idoso , Ligas , Constrição Patológica/diagnóstico por imagem , Constrição Patológica/cirurgia , Procedimentos Endovasculares/efeitos adversos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sistema de Registros , Stents Metálicos Autoexpansíveis/efeitos adversos , Resultado do Tratamento , Ultrassonografia Doppler Dupla , Grau de Desobstrução Vascular , Veia Cava Inferior/diagnóstico por imagem , Veia Cava Inferior/patologia , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/cirurgia
19.
Vasa ; 47(4): 319-325, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29512422

RESUMO

BACKGROUND: The aim of the study was to investigate venous patency and clinical outcomes for endovascular treatment of iliofemoral venous obstruction in patients with post-thrombotic syndrome (PTS) and non-thrombotic iliac vein lesion (NIVL) with dedicated self-expanding nitinol stents. PATIENTS AND METHODS: Data were collected from the prospective Swiss Venous Stent Registry, enrolling consecutive patients with a standardized follow-up procedure since January 2008. Patency was evaluated by duplex sonography and clinical outcome by various scores including the Villalta score at baseline, three, six, and 12 months, and then annually after endovascular therapy. RESULTS: Overall, 93 patients (64 PTS, 29 NIVL) were analysed. Mean follow-up time was 20 ± 16 (range 3-70) months. A total of 11 (12 %) patients had a stent occlusion, all of which occurred in the PTS group, and 13 (14 %) patients had a symptomatic stent stenosis. Primary patency was 79 % (95 % CI 68-87 %) at 12 months and 72 % (95 % CI 59-82 %) at 24 months. In PTS patients, primary patency at 12 months was 75 % (95 % CI 61-84 %) vs. 89 % (95 % CI 63-97 %) in NIVL patients (p = 0.10). Secondary patency at 24 months was 94 % (95 % CI 84-98 %) in PTS and 100 % in NIVL, p = 0.19). Overall, 62 (67 %) patients were free from PTS at the latest follow-up with a Villalta score < 5 points. Predictive factors for the loss of primary patency were stents placed below the inguinal ligament (OR 2.59, 95 % CI, 0.99-6.84, p = 0.05). CONCLUSIONS: In symptomatic patients with chronic iliofemoral vein obstruction, endovascular therapy with self-expanding nitinol stents was associated with favourable patency rates and clinical improvement in the majority of patients.


Assuntos
Ligas , Procedimentos Endovasculares/instrumentação , Veia Femoral , Veia Ilíaca , Síndrome Pós-Trombótica/terapia , Stents Metálicos Autoexpansíveis , Insuficiência Venosa/terapia , Adulto , Idoso , Doença Crônica , Procedimentos Endovasculares/efeitos adversos , Feminino , Veia Femoral/diagnóstico por imagem , Veia Femoral/fisiopatologia , Humanos , Veia Ilíaca/diagnóstico por imagem , Veia Ilíaca/fisiopatologia , Masculino , Pessoa de Meia-Idade , Síndrome Pós-Trombótica/diagnóstico por imagem , Síndrome Pós-Trombótica/fisiopatologia , Desenho de Prótese , Sistema de Registros , Suíça , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler Dupla , Grau de Desobstrução Vascular , Insuficiência Venosa/diagnóstico por imagem , Insuficiência Venosa/fisiopatologia
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