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1.
Medicine (Baltimore) ; 100(1): e24002, 2021 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-33429763

RESUMO

ABSTRACT: We aimed to investigate the prevalence of pulmonary thromboembolism (PTE) and its association with clinical variables in a cohort of hospitalized coronavirus disease 2019 (COVID-19) patients receiving low-molecular-weight heparin (LMWH) at prophylactic dosage.In this retrospective observational study we included COVID-19 patients receiving prophylactic LMWH from admission but still referred for lower-limbs venous Doppler ultrasound (LL-US) and computed tomography pulmonary angiography (CTPA) for clinical PTE suspicion. A dedicated radiologist reviewed CTPA images to assess PTE presence/extension.From March 1 to April 30, 2020, 45 patients were included (34 men, median age 67 years, interquartile range [IQR] 60-76). Twenty-seven (60%) had PTE signs at CTPA, 17/27 (63%) with bilateral involvement, none with main branch PTE. In 33/45 patients (73%) patients LL-US was performed before CTPA, with 3 patients having superficial vein thrombosis (9%, none with CTPA-confirmed PTE) and 1 patient having deep vein thrombosis (3%, with CTPA-confirmed PTE). Thirty-three patients (73%) had at least one comorbidity, mainly hypertension (23/45, 51%) and cardiovascular disease (15/45, 33%). Before CTPA, 5 patients had high D-dimer (11.21 µg/mL, IQR 9.10-13.02), 19 high fibrinogen (550 mg/dL, IQR 476-590), 26 high interleukin-6 (79 pg/mL, IQR 31-282), and 11 high C-reactive protein (9.60 mg/dL, IQR 6.75-10.65), C-reactive protein being the only laboratory parameter significantly differing between patients with and without PTE (P = .002)High PTE incidence (60%) in COVID-19 hospitalized patients under prophylactic LMWH could substantiate further tailoring of anticoagulation therapy.


Assuntos
Anticoagulantes/uso terapêutico , Heparina de Baixo Peso Molecular/uso terapêutico , Embolia Pulmonar/epidemiologia , Terapia Trombolítica , Idoso , Angiografia por Tomografia Computadorizada , Feminino , Hospitalização , Humanos , Incidência , Masculino , Prevalência , Embolia Pulmonar/prevenção & controle , Estudos Retrospectivos , Fatores de Risco , Ultrassonografia Doppler , Tromboembolia Venosa/diagnóstico por imagem , Tromboembolia Venosa/prevenção & controle
2.
PLoS One ; 15(11): e0242475, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33211737

RESUMO

BACKGROUND: COVID-19 is frequently complicated by venous thromboembolism (VTE). Computed tomography (CT) of the chest-primarily usually conducted as low-dose, non-contrast enhanced CT-plays an important role in the diagnosis and follow-up of COVID-19 pneumonia. Performed as contrast-enhanced CT pulmonary angiography, it can reliably detect or rule-out pulmonary embolism (PE). Several imaging characteristics of COVID-19 pneumonia have been described for chest CT, but no study evaluated CT findings in the context of VTE/PE. PURPOSE: In our retrospective study, we analyzed clinical, laboratory and CT imaging characteristics of 50 consecutive patients with RT-PCR proven COVID-19 pneumonia who underwent contrast-enhanced chest CT at two tertiary care medical centers. MATERIAL AND METHODS: All patients with RT-PCR proven COVID-19 pneumonia and contrast-enhanced chest CT performed at two tertiary care hospitals between March 1st and April 20th 2020 were retrospectively identified. Patient characteristics (age, gender, comorbidities), symptoms, date of symptom onset, RT-PCR results, imaging results of CT and leg ultrasound, laboratory findings (C-reactive protein, differential blood count, troponine, N-terminal pro-B-type natriuretic peptide (NT-proBNP), fibrinogen, interleukin-6, D-dimer, lactate dehydrogenase (LDH), creatine kinase (CK), creatine kinase muscle-brain (CKmb) and lactate,) and patient outcome (positive: discharge or treatment on normal ward; negative: treatment on intensive care unit (ICU), need for mechanical ventilation, extracorporeal membrane oxygenation (ECMO), or death) were analyzed. Follow-up was performed until May 10th. Patients were assigned to two groups according to two endpoints: venous thromboembolism (VTE) or no VTE. For statistical analysis, univariate logistic regression models were calculated. RESULTS: This study includes 50 patients. In 14 out of 50 patients (28%), pulmonary embolism was detected at contrast-enhanced chest CT. The majority of PE was detected on CTs performed on day 11-20 after symptom onset. Two patients (14%) with PE simultaneously had evidence of deep vein thrombosis. 15 patients (30%) had a negative outcome (need for intensive care, mechanical ventilation, extracorporeal membrane oxygenation, or death), and 35 patients (70%) had a positive outcome (transfer to regular ward, or discharge). Patients suffering VTE had a statistically significant higher risk of an unfavorable outcome (p = 0.028). In univariate analysis, two imaging characteristics on chest CT were associated with VTE: crazy paving pattern (p = 0.024) and air bronchogram (n = 0.021). Also, elevated levels of NT-pro BNP (p = 0.043), CK (p = 0.023) and D-dimers (p = 0.035) were significantly correlated with VTE. CONCLUSION: COVID-19 pneumonia is frequently complicated by pulmonary embolism (incidence of 28% in our cohort), remarkably with lacking evidence of deep vein thrombosis in nearly all thus affected patients of our cohort. As patients suffering VTE had an adverse outcome, we call for a high level of alertness for PE and advocate a lower threshold for contrast-enhanced CT in COVID-19 pneumonia. According to our observations, this might be particularly justified in the second week of disease and if a crazy paving pattern and / or air bronchogram is present on previous non-enhanced CT.


Assuntos
Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Embolia Pulmonar/diagnóstico por imagem , Tórax , Tromboembolia Venosa/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Betacoronavirus , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Pandemias , Embolia Pulmonar/etiologia , Estudos Retrospectivos , Tórax/patologia , Tórax/ultraestrutura , Tromboembolia Venosa/etiologia
3.
J Vasc Interv Radiol ; 31(10): 1529-1544, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32919823

RESUMO

PURPOSE: To provide evidence-based recommendations on the use of inferior vena cava (IVC) filters in the treatment of patients with or at substantial risk of venous thromboembolic disease. MATERIALS AND METHODS: A multidisciplinary expert panel developed key questions to address in the guideline, and a systematic review of the literature was conducted. Evidence was graded based on a standard methodology, which was used to inform the development of recommendations. RESULTS: The systematic review identified a total of 34 studies that provided the evidence base for the guideline. The expert panel agreed on 18 recommendations. CONCLUSIONS: Although the evidence on the use of IVC filters in patients with or at risk of venous thromboembolic disease varies in strength and quality, the panel provides recommendations for the use of IVC filters in a variety of clinical scenarios. Additional research is needed to optimize care for this patient population.


Assuntos
Implantação de Prótese/instrumentação , Implantação de Prótese/normas , Radiologia Intervencionista/normas , Filtros de Veia Cava/normas , Tromboembolia Venosa/terapia , Consenso , Humanos , Segurança do Paciente/normas , Desenho de Prótese , Implantação de Prótese/efeitos adversos , Fatores de Risco , Resultado do Tratamento , Tromboembolia Venosa/diagnóstico por imagem , Tromboembolia Venosa/etiologia
4.
Arterioscler Thromb Vasc Biol ; 40(10): 2527-2538, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32757649

RESUMO

OBJECTIVE: Deep vein thrombosis and pulmonary embolism referred as venous thromboembolism (VTE) are a common cause of morbidity and mortality. Plasma from healthy controls or individuals who have experienced a VTE were analyzed using metabolomics to characterize biomarkers and metabolic systems of patients with VTE. Approach and Results: Polar metabolite and lipidomic profiles from plasma collected 3 months after an incident VTE were obtained using liquid chromatography mass spectrometry. Fasting-state plasma samples from 42 patients with VTE and 42 healthy controls were measured. Plasma metabolomic profiling identified 512 metabolites forming 62 biological clusters. Multivariate analysis revealed a panel of 21 metabolites altogether capable of predicting VTE status with an area under the curve of 0.92 (P=0.00174, selectivity=0.857, sensitivity=0.971). Multiblock systems analysis revealed 25 of the 62 functional biological groups as significantly affected in the VTE group (P<0.05 to control). Complementary correlation network analysis of the dysregulated functions highlighted a subset of the lipidome composed mainly of n-3 long-chain polyunsaturated fatty acids within the predominant triglycerides as a potential regulator of the post-VTE event biological response, possibly controlling oxidative and inflammatory defence systems, and metabolic disorder associated dysregulations. Of interest was microbiota metabolites including trimethylamine N-oxide that remained associated to post incident VTE patients, highlighting a possible involvement of gut microbiota on VTE risk and relapse. CONCLUSIONS: These findings show promise for the elucidation of underlying mechanisms and the design of a diagnostic test to assess the likely efficacy of clinical care in patients with VTE.


Assuntos
Metabolismo Energético , Lipídeos/sangue , Metabolômica , Embolia Pulmonar/sangue , Biologia de Sistemas , Tromboembolia Venosa/sangue , Trombose Venosa/sangue , Adulto , Idoso , Biomarcadores/sangue , Estudos de Casos e Controles , Feminino , Microbioma Gastrointestinal , Humanos , Incidência , Lipidômica , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/epidemiologia , Recidiva , Fatores de Tempo , Tromboembolia Venosa/diagnóstico por imagem , Tromboembolia Venosa/epidemiologia , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/epidemiologia
5.
Chest ; 158(5): 2130-2135, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32710891
7.
Circ Cardiovasc Imaging ; 13(5): e010651, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32418452

RESUMO

BACKGROUND: The choice of the imaging modality for diagnosis of pulmonary embolism (PE) could be influenced by provider, patient or hospital characteristics, or over time. However, little is known about the choice of the diagnostic modalities in practice. The aim of this study was to evaluate the variations in the use of imaging modalities for patients with acute PE. METHODS: Using the data from Registro Informatizado Enfermedad TromboEmbolica (RIETE), a prospective international registry of patients with venous thromboembolism (March 2001-January 2019), we explored the imaging modalities used in patients with acute PE. The imaging modalities included computed tomography pulmonary angiography, ventilation/perfusion scanning, pulmonary angiography, a combination of these tests, or PE signs and symptoms plus imaging-confirmed proximal deep vein thrombosis but no chest imaging. RESULTS: Among 38 025 patients with confirmed PE (53.1% female, age: 67.3±17 years), computed tomography pulmonary angiography was the dominant modality of diagnosis in all RIETE enrollees (78.2% [99% CI, 77.6-78.7]); including pregnant patients (58.9% [99% CI, 47.7%-69.4%]) and patients with severe renal insufficiency (62.5% [99% CI, 59.9-65.0]). A greater proportion of patients underwent ventilation/perfusion scanning in larger hospitals compared with smaller hospitals (13.1% versus 7.3%, P<0.001). The use of computed tomography pulmonary angiography varied between 13.3% and 98.3% across the countries, and its use increased over time (46.5% in 2002 to 91.7% in 2018, P<0.001). CONCLUSIONS: In a large multinational PE registry, variations were observed in the use of imaging modalities according to patient or institutional factors and over time. However, computed tomography pulmonary angiography was the dominant modality of diagnosis, even in pregnancy and severe renal insufficiency. The safety, costs, and downstream effects of these tests on PE-related and non-PE-related outcomes warrant further investigation.


Assuntos
Diagnóstico por Imagem/tendências , Disparidades em Assistência à Saúde/tendências , Padrões de Prática Médica/tendências , Embolia Pulmonar/diagnóstico por imagem , Tromboembolia Venosa/diagnóstico por imagem , Trombose Venosa/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Angiografia por Tomografia Computadorizada/tendências , Feminino , Nível de Saúde , Hospitalização/tendências , Hospitais com Alto Volume de Atendimentos/tendências , Hospitais com Baixo Volume de Atendimentos/tendências , Humanos , Angiografia por Ressonância Magnética/tendências , Masculino , Pessoa de Meia-Idade , Imagem de Perfusão/tendências , Flebografia/tendências , Valor Preditivo dos Testes , Gravidez , Estudos Prospectivos , Embolia Pulmonar/terapia , Sistema de Registros , Fatores de Tempo , Ultrassonografia/tendências , Tromboembolia Venosa/terapia , Trombose Venosa/terapia
8.
Thromb Res ; 191: 9-14, 2020 07.
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.


Assuntos
Arteriopatias Oclusivas/etiologia , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Trombofilia/etiologia , Tromboembolia Venosa/etiologia , Síndrome Coronariana Aguda/epidemiologia , Síndrome Coronariana Aguda/etiologia , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial , Anticoagulantes/uso terapêutico , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/epidemiologia , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/etiologia , Comorbidade , Trombose Coronária/diagnóstico por imagem , Trombose Coronária/epidemiologia , Trombose Coronária/etiologia , Cuidados Críticos , Coagulação Intravascular Disseminada/epidemiologia , Coagulação Intravascular Disseminada/etiologia , Feminino , Mortalidade Hospitalar , Hospitais de Ensino/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Itália/epidemiologia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pandemias , Admissão do Paciente , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/etiologia , Estudos Retrospectivos , Fatores de Risco , Trombofilia/tratamento farmacológico , Tromboembolia Venosa/diagnóstico por imagem , Tromboembolia Venosa/epidemiologia
10.
J Thromb Haemost ; 18(8): 1995-2002, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32369666

RESUMO

BACKGROUND: Coronavirus disease 2019 (COVID-19) can lead to systemic coagulation activation and thrombotic complications. OBJECTIVES: To investigate the incidence of objectively confirmed venous thromboembolism (VTE) in hospitalized patients with COVID-19. METHODS: Single-center cohort study of 198 hospitalized patients with COVID-19. RESULTS: Seventy-five patients (38%) were admitted to the intensive care unit (ICU). At time of data collection, 16 (8%) were still hospitalized and 19% had died. During a median follow-up of 7 days (IQR, 3-13), 39 patients (20%) were diagnosed with VTE of whom 25 (13%) had symptomatic VTE, despite routine thrombosis prophylaxis. The cumulative incidences of VTE at 7, 14 and 21 days were 16% (95% CI, 10-22), 33% (95% CI, 23-43) and 42% (95% CI 30-54) respectively. For symptomatic VTE, these were 10% (95% CI, 5.8-16), 21% (95% CI, 14-30) and 25% (95% CI 16-36). VTE appeared to be associated with death (adjusted HR, 2.4; 95% CI, 1.02-5.5). The cumulative incidence of VTE was higher in the ICU (26% (95% CI, 17-37), 47% (95% CI, 34-58), and 59% (95% CI, 42-72) at 7, 14 and 21 days) than on the wards (any VTE and symptomatic VTE 5.8% (95% CI, 1.4-15), 9.2% (95% CI, 2.6-21), and 9.2% (2.6-21) at 7, 14, and 21 days). CONCLUSIONS: The observed risk for VTE in COVID-19 is high, particularly in ICU patients, which should lead to a high level of clinical suspicion and low threshold for diagnostic imaging for DVT or PE. Future research should focus on optimal diagnostic and prophylactic strategies to prevent VTE and potentially improve survival.


Assuntos
Betacoronavirus , Infecções por Coronavirus/sangue , Pandemias , Pneumonia Viral/sangue , Embolia Pulmonar/epidemiologia , Tromboembolia Venosa/epidemiologia , Trombose Venosa/epidemiologia , Idoso , Anticoagulantes/uso terapêutico , Biomarcadores , Cateterismo Venoso Central/efeitos adversos , Infecções por Coronavirus/complicações , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Incidência , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Quartos de Pacientes/estatística & dados numéricos , Pneumonia Viral/complicações , Embolia Pulmonar/sangue , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/etiologia , Estudos Retrospectivos , Fatores de Risco , Trombofilia/tratamento farmacológico , Trombofilia/etiologia , Tromboflebite/epidemiologia , Tromboflebite/etiologia , Tromboembolia Venosa/sangue , Tromboembolia Venosa/diagnóstico por imagem , Tromboembolia Venosa/etiologia , Trombose Venosa/sangue , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/etiologia
12.
Am J Emerg Med ; 38(7): 1544.e1-1544.e3, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32312574

RESUMO

Recent retrospective studies from Wuhan, China suggest Novel Coronavirus Disease 2019 (COVID-19) may be associated with a hypercoagulable state and increased risk for venous thromboembolism. The overlap in the signs and symptoms of COVID-19 associated Acute Respiratory Distress Syndrome (ARDS) and COVID-19 with concurrent pulmonary embolism creates a diagnostic challenge for emergency medicine physicians in patients already at risk for renal impairment. However, identifying features atypical for COVID-19 alone may play a role in the judicious use of Computed Tomography Angiography among these patients. Hemoptysis is seen in roughly 13% of pulmonary embolism cases and infrequently reported among COVID-19 infections. Additionally, the presence of right heart strain on electrocardiography (EKG) is a well described clinical presentations of pulmonary embolism not reported commonly with COVID-19 infections.


Assuntos
Infecções por Coronavirus/complicações , Hemoptise/etiologia , Pneumonia Viral/complicações , Embolia Pulmonar/virologia , Tromboembolia Venosa/virologia , Doença Aguda , Adulto , Betacoronavirus , Angiografia por Tomografia Computadorizada , Infecções por Coronavirus/diagnóstico , Eletrocardiografia , Humanos , Masculino , Pandemias , Pneumonia Viral/diagnóstico , Embolia Pulmonar/diagnóstico por imagem , Tromboembolia Venosa/diagnóstico por imagem
13.
J Thorac Cardiovasc Surg ; 160(4): 1064-1073, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32113716

RESUMO

OBJECTIVE: The purpose of this study was to determine the incidence of venous thromboembolism and utility of a routine surveillance program in patients undergoing surgery for mesothelioma. METHODS: Patients undergoing pleurectomy from May 2016 to August 2018 were included. A standardized surveillance program to look for venous thromboembolism in this group included noninvasive studies every 7 days postoperatively or earlier if symptomatic. All patients received external pneumatic compression sleeves in addition to prophylactic heparin. If deep vein thrombosis or pulmonary embolus was discovered, heparin drip was initiated until conversion to therapeutic anticoagulation. RESULTS: A total of 100 patients underwent pleurectomy for mesothelioma. Seven patients were found to have preoperative deep vein thrombosis, and as such only 93 patients were included for analysis. The median age of patients at surgery was 71 years (30-85 years). During the study, 30 patients (32%) developed evidence of thrombosis; 20 patients (22%) developed only deep vein thrombosis without embolism, 3 patients (3%) developed only pulmonary embolism, and 7 patients (7%) developed both deep vein thrombosis and pulmonary embolus. Of the 27 patients who developed deep vein thrombosis, 9 (33%) were asymptomatic at the time of diagnosis, and none of these developed a pulmonary embolus or other bleeding complications. There were 2 (2%) events of major postoperative bleeding related to therapeutic anticoagulation. CONCLUSIONS: The incidence of venous thromboembolism is high (32%) among patients undergoing surveillance after pleurectomy for mesothelioma. Up to 33% of patients with deep vein thrombosis are asymptomatic at the time of diagnosis, and the incidence of complications related to anticoagulation is low. Routine surveillance may be useful to diagnose and treat deep vein thrombosis before it progresses to symptomatic or fatal pulmonary embolus.


Assuntos
Neoplasias Pulmonares/cirurgia , Mesotelioma/cirurgia , Neoplasias Pleurais/cirurgia , Embolia Pulmonar/epidemiologia , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Tromboembolia Venosa/epidemiologia , Trombose Venosa/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Boston/epidemiologia , Feminino , Heparina/administração & dosagem , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/tratamento farmacológico , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Tromboembolia Venosa/diagnóstico por imagem , Tromboembolia Venosa/tratamento farmacológico , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/tratamento farmacológico
14.
Am Surg ; 86(2): 104-109, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-32167051

RESUMO

Deep vein thrombosis (DVT) is linked to reimbursements and publicly reported metrics. Some hospitals discourage venous duplex ultrasound (VDUS) screening in asymptomatic trauma patients because they often find higher rates of DVT. We aim to evaluate the association between lower extremity (LE) VDUS screening and pulmonary embolism (PE) in trauma patients. Trauma patients admitted to an urban Level-1 trauma center between 2010 and 2015 were retrospectively analyzed. We characterized the association of asymptomatic LE VDUSs with PE, upper extremity DVT, proximal LE DVT, and distal LE DVT by univariate and multivariable logistic regression controlling for confounders. Of the 3959 trauma patients included in our study-after adjusting for covariates related to patient demographics, injury, and procedures-there was a significantly lower likelihood of PE in screened patients (odds ratio (OR) = 0.02, P < 0.001) and a higher rate of distal LE DVT (OR 11.1, P = 0.004). Screening was not associated with higher rates of proximal LE DVT after adjustment for covariates (OR = 1.8, P = 0.193). PE was associated with patient transfer status, pelvis fracture, and spinal procedures in unscreened patients. After adjusting for covariates, we have shown that LE VDUS asymptomatic screening is associated with lower rates of PE in trauma patients and not associated with higher rates of proximal LE DVT. Our detailed institutional review of a large cohort of trauma patients over five years provides support for ongoing asymptomatic screening and better characterizes venous thromboembolism outcomes than similarly sized purely administrative data reviews. As a retrospective cohort study with a large sample size, no loss to follow-up, and a population with low heterogeneity, this study should be considered as level III evidence for care management.


Assuntos
Doenças Assintomáticas , Embolia Pulmonar/diagnóstico por imagem , Tromboembolia Venosa/diagnóstico por imagem , Trombose Venosa/diagnóstico por imagem , Ferimentos e Lesões/complicações , Feminino , Humanos , Tempo de Internação , Modelos Logísticos , Extremidade Inferior/irrigação sanguínea , Extremidade Inferior/diagnóstico por imagem , Masculino , Razão de Chances , Embolia Pulmonar/complicações , Embolia Pulmonar/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Ultrassonografia Doppler Dupla/estatística & dados numéricos , Tromboembolia Venosa/complicações , Trombose Venosa/complicações
15.
Rev. clín. esp. (Ed. impr.) ; 220(2): 126-134, mar. 2020. ilus, graf
Artigo em Espanhol | IBECS | ID: ibc-186426

RESUMO

La ecografía clínica se ha desarrollado exponencialmente en la última década en distintos ámbitos de la medicina. De igual manera que ha ocurrido en otros campos de actuación de la medicina interna, su uso se ha implantado en la enfermedad tromboembólica venosa, tanto en la trombosis venosa profunda como en la embolia pulmonar. En esta revisión se repasan las técnicas para el diagnóstico, tanto de la trombosis venosa profunda a través de la ultrasonografía por compresión, como de la ecografía multiórgano que incluye la ultrasonografía por compresión, la ecografía pulmonar en busca de infartos pulmonares y la ecocardioscopia para la detección de dilatación y/o disfunción del ventrículo derecho, para el diagnóstico de la embolia pulmonar. Además, se plantean los escenarios clínicos más frecuentes en los que puede ser de ayuda la ecografía clínica en la vida real, así como sus limitaciones y la evidencia existente


The use of clinical ultrasonography has grown exponentially in the past decade in various medical settings. As with other areas of activity in the field of internal medicine, clinical ultrasonography has been implemented in venous thromboembolism disease, both in deep vein thrombosis and pulmonary embolism. In this review, we cover the diagnostic techniques, both for deep vein thrombosis through compression ultrasonography and for multiorgan ultrasonography, which include compression ultrasonography, pulmonary ultrasonography in the search for pulmonary infarctions and echocardiography for detecting dilation and right ventricular dysfunction for the diagnosis of pulmonary embolism. We also establish the most common clinical scenarios in which clinical ultrasonography can be of assistance in actual clinical practice, as well as its limitations and current evidence


Assuntos
Humanos , Ultrassonografia/métodos , Tromboembolia Venosa/diagnóstico por imagem , Trombose Venosa/diagnóstico por imagem , Embolia Pulmonar/diagnóstico por imagem , Endossonografia/métodos , Tratamento de Emergência/métodos , Sensibilidade e Especificidade , Ultrassonografia Doppler em Cores/métodos
17.
J Am Coll Cardiol ; 75(2): 148-158, 2020 01 21.
Artigo em Inglês | MEDLINE | ID: mdl-31948643

RESUMO

BACKGROUND: Heart failure (HF) hospitalization places patients at increased short-term risk for venous thromboembolism (VTE). Long-term risk for VTE associated with incident HF, HF subtypes, or structural heart disease is unknown. OBJECTIVES: In the ARIC (Atherosclerosis Risk In Communities) cohort, VTE risk associated with incident HF, HF subtypes, and abnormal echocardiographic measures in the absence of clinical HF was assessed. METHODS: During follow-up, ARIC identified incident HF and subcategorized HF with preserved ejection fraction or reduced ejection fraction. At the fifth clinical examination, echocardiography was performed. Physicians adjudicated incident VTE using hospital records. Adjusted Cox proportional hazards models were used to evaluate the association between HF or echocardiographic exposures and VTE. RESULTS: Over a mean of 22 years in 13,728 subjects, of whom 2,696 (20%) developed incident HF, 729 subsequent VTE events were identified. HF was associated with increased long-term risk for VTE (adjusted hazard ratio: 3.13; 95% confidence interval: 2.58 to 3.80). In 7,588 subjects followed for a mean of 10 years, the risk for VTE was similar for HF with preserved ejection fraction (adjusted hazard ratio: 4.71; 95% CI: 2.94 to 7.52) and HF with reduced ejection fraction (adjusted hazard ratio: 5.53; 95% confidence interval: 3.42 to 8.94). In 5,438 subjects without HF followed for a mean of 3.5 years, left ventricular relative wall thickness and mean left ventricular wall thickness were independent predictors of VTE. CONCLUSIONS: In this prospective population-based study, incident hospitalized HF (including both heart failure with preserved ejection fraction and reduced ejection fraction), as well as echocardiographic indicators of left ventricular remodeling, were associated with greatly increased risk for VTE, which persisted through long-term follow-up. Evidence-based strategies to prevent long-term VTE in patients with HF, beyond time of hospitalization, are needed.


Assuntos
Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/epidemiologia , Tromboembolia Venosa/diagnóstico por imagem , Tromboembolia Venosa/epidemiologia , Feminino , Seguimentos , Insuficiência Cardíaca/fisiopatologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Volume Sistólico/fisiologia , Fatores de Tempo , Tromboembolia Venosa/fisiopatologia
18.
J Vasc Surg Venous Lymphat Disord ; 8(1): 31-41, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31495765

RESUMO

BACKGROUND: The thrombodynamic test (TD) is a novel global test of hemostasis that allows to study the spatial-temporal characteristics of a clot formation in real time under conditions close to natural ones and demonstrates high sensitivity to detect the state of hypercoagulation. The main paraments of the test are the velocity of clot growth, clot's size, and clot density. The objective of this study was to compare the classic Caprini 2005 score and its modified version in association with the results of TD. The goal is to predict postoperative venous thromboembolism (VTE) in surgical patients undergoing surgery for colorectal cancer. METHODS: This was a prospective observational clinical study involving 80 patients (33 men and 47 women; mean age, 73.9 ± 7.2 years) who underwent major (79 cases) or minor (1 case) surgery for colorectal cancer. Patients were at high risk for postoperative VTE (ie, a mean Caprini score of 9.9 ± 2.0) and received combined prophylaxis (ie, antiembolic compression stockings and enoxaparin 40 mg once daily) until discharge. Enoxaparin was administered at a fixed time of blood sampling for the TD test. Duplex ultrasound scan was performed to detect postoperative vein thrombosis before and 5 to 7 days after surgery. RESULTS: Postoperative vein thrombosis was found in 21 of 80 patients (26.3%; 95% confidence interval, 17.9%-36.8%). Regression analysis and receiver operating characteristic (ROC) curve showed that Caprini scores significantly predicted VTE (P < .0001; area under the curve [AUC] = 0.839 ± 0.045). Analysis of ROC curve coordinates showed that a cutoff point of 11 scores had a sensitivity of 76.2% and a specificity of 74.6%. The results of the TD test showed significant hypercoagulation despite enoxaparin administration in patients with VTE. Regression analysis and ROC curves demonstrated that the following TD parameters had the greatest predictability for postoperative DVT: initial velocity of clot growth (Vin) and clot size (CS) measured at 12 hours after enoxaparin administration (AUC, 0.697 ± 0.063 and AUC, 0.790 ± 0.059, respectively), as well as Vin and CS measured 24 hours after the enoxaparin injection (S = 0.847 ± 0.059 and S = 0.803 ± 0.069, respectively). The cutoff points for VTE prediction at 12 and 24 hours seemed to be a Vin of greater than 62.5 and greater than 64.5 µm/minute (normal range, 35-56 µm/minute) as well as a CS of greater than 1351.5 and greater than 1333.5 µm (normal range, 800-1200 µm), respectively. Identified thresholds for TD parameters have been integrated into Caprini scores under the item "other congenital or acquired thrombophilia." The total Caprini scores were recalculated in patients where one or all TD parameters had exceeded the cutoff followed by reanalysis of the ROC curves. The best predictability was found for Caprini scores considering the elevation of all four TD parameters (AUC, 0.924 ± 0.029) with increased cutoff to a score of 12 with a sensitivity of 85.7% and a specificity of 81.4%. The use of cutoffs for the original and modified scores could be used to calculate the number of patients that were under cutoff but developed with VTE: 10.2% and 5.9%, respectively. CONCLUSIONS: Integrating TD parameters into the Caprini score increases the ability to predict postoperative VTE.


Assuntos
Coagulação Sanguínea , Neoplasias Colorretais/cirurgia , Técnicas de Apoio para a Decisão , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Tromboembolia Venosa/etiologia , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Testes de Coagulação Sanguínea , Neoplasias Colorretais/sangue , Neoplasias Colorretais/complicações , Neoplasias Colorretais/diagnóstico , Enoxaparina/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Meias de Compressão , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler Dupla , Tromboembolia Venosa/sangue , Tromboembolia Venosa/diagnóstico por imagem , Tromboembolia Venosa/prevenção & controle
19.
Catheter Cardiovasc Interv ; 95(3): 462-466, 2020 02 15.
Artigo em Inglês | MEDLINE | ID: mdl-31595624

RESUMO

We describe the case of a 72-year-old gentleman who was referred to our institution for management of cardiogenic shock from a massive pulmonary embolism. Right heart catheterization revealed a low cardiac index and markedly elevated pulmonary pressures, suggested long-standing venous thromboembolic (VTE) disease that evolved into chronic thromboembolic pulmonary hypertension (CTEPH). The patient was cannulated to veno-arterial extra-corporeal membrane oxygenation and eventually treated with pulmonary embolectomy and thromboendarterectomy. Subsequently discovered inferior vena cava clot and left iliac deep vein thrombosis were treated with suction and mechanical thrombectomy. Intravascular ultrasound of the left lower extremity venous system identified iliac vein compression syndrome (IVCS) as the culprit of the patient's VTE and CTEPH. A left iliac stent was placed and the patient was discharged on Warfarin for anticoagulation. The case illustrates the rapidly expanding armamentarium for VTE treatment and proposes IVCS as a new, potentially underrecognized risk factor for CTEPH.


Assuntos
Hipertensão Pulmonar/etiologia , Síndrome de May-Thurner/complicações , Embolia Pulmonar/etiologia , Tromboembolia Venosa/terapia , Trombose Venosa/etiologia , Idoso , Anticoagulantes/uso terapêutico , Embolectomia , Endarterectomia , Procedimentos Endovasculares/instrumentação , Oxigenação por Membrana Extracorpórea , Hemodinâmica , Humanos , Hipertensão Pulmonar/diagnóstico por imagem , Hipertensão Pulmonar/fisiopatologia , Hipertensão Pulmonar/terapia , Masculino , Síndrome de May-Thurner/diagnóstico por imagem , Síndrome de May-Thurner/fisiopatologia , Síndrome de May-Thurner/terapia , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/fisiopatologia , Embolia Pulmonar/terapia , Fatores de Risco , Stents , Trombectomia , Resultado do Tratamento , Tromboembolia Venosa/diagnóstico por imagem , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/fisiopatologia , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/fisiopatologia , Trombose Venosa/terapia , Varfarina/uso terapêutico
20.
Ann Vasc Surg ; 65: 82-89, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-31678541

RESUMO

BACKGROUND: The optimal approach for assessing the risk of venous thromboembolism (VTE) in patients undergoing plastic surgery is yet to be established. This study aimed to determine the validity of the Caprini Risk Assessment Scale in identifying patients undergoing plastic surgery who are at a high risk of developing VTE. METHODS: Between December 2014 and November 2015, we enrolled 90 patients. Risk factors for VTE were assessed at baseline. The Caprini Risk Assessment Model was used to stratify patients into Caprini <4, Caprini 5-6, Caprini 7-8, and Caprini >8 groups before examination. We preoperatively screened for deep vein thrombosis (DVT) using duplex ultrasound. During operation, surgical duration and blood loss were recorded. Duplex ultrasound was repeated 2 and 7 days postoperatively to evaluate for DVT. We used a univariate analysis to determine risk factors for postoperative VTE. Confounding predictors were finally tested using a multivariate logistic regression analysis. RESULTS: One patient had preoperative DVT and was excluded from the study. Eighty-nine patients were included in the final analyses. Of the 89 patients, 7 (8%) developed postoperative DVT. Mean age, body mass index, Caprini score, and surgical duration were significantly higher in patients who developed postoperative DVT. Variables associated with increased risk of postoperative DVT using univariate analysis were Caprini scores of 7-8 and >8. Multivariate logistic regression analysis finally identified Caprini scores 7-8 [odds ratio (OR) 13, 95% confidence interval (CI) 1.67-101.98, P = 0.014] and >8 (OR 19.5, 95% CI 1.02-371.96, P = 0.048) to be independently associated with postoperative DVT. CONCLUSIONS: Although the incidence of postoperative DVT is relatively low among patients undergoing plastic surgery, Caprini scores can be used to predict postoperative VTE complications.


Assuntos
Técnicas de Apoio para a Decisão , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Tromboembolia Venosa/etiologia , Trombose Venosa/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Feminino , Humanos , Dispositivos de Compressão Pneumática Intermitente , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Meias de Compressão , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler em Cores , Tromboembolia Venosa/diagnóstico por imagem , Tromboembolia Venosa/prevenção & controle , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/prevenção & controle , Adulto Jovem
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