Different risk of deep vein thrombosis and pulmonary embolism in carriers with factor V Leiden compared with non-carriers, but not in other thrombophilic defects. Results from a large retrospective family cohort study

The term factor V Leiden (FVL) paradox is used to describe the different risk of deep vein thrombosis and pulmonary embolism that has been found in carriers of FVL. In a thrombophilic family-cohort, we estimated differences in absolute risks of deep vein thrombosis and pulmonary embolism for various thrombophilic defects. Of 2,054 relatives, 1,131 were female, 41 had pulmonary embolism and 126 deep vein thrombosis. Annual incidence for deep vein thrombosis in non-carriers of FVL was 0.19% (95%CI, 0.16–0.23), and 0.41% (95%CI, 0.28–0.58) in carriers; relative risk (RR) 2.1 (95%CI, 1.4–3.2). For pulmonary embolism these incidences were similar in carriers and non-carriers 0.07%, respectively; RR 1.0 (95% CI, 0.4–2.5). When co-inheritance of other thrombophilic defects was excluded the RR for deep vein thrombosis in FVL carriers was 7.0 (95%CI, 2.3–21.7) compared to non-carriers and 2.8 (95%CI, 0.5–14.4) for pulmonary embolism. For other thrombophilic defects no such effect was observed. Thus the FVL paradox was confirmed in our study. However, a similar paradox in carriers of other thrombophilic defects was not observed.     

Venous thromboembolism in patients hospitalized with nephrotic syndrome

Purpose

Whether pulmonary embolism in patients with the nephrotic syndrome is caused by deep venous thrombosis or renal vein thrombosis is controversial. To determine which is the likely cause of pulmonary embolism in patients with the nephrotic syndrome, we investigated data from the National Hospital Discharge Survey.

Methods

The number of patients discharged from nonfederal short-stay hospitals in the United States with a diagnostic code of nephrotic syndrome, deep venous thrombosis, renal vein thrombosis, and pulmonary embolism was obtained using ICD-9-M (International Classification of Diseases, Ninth Revision, Clinical Modification) codes.

Results

From 1979 to 2005, 925,000 patients were discharged from hospitals with the nephrotic syndrome and 898,253,000 patients did not have the nephrotic syndrome. With the nephrotic syndrome, 5000 (0.5%) had pulmonary embolism, 14,000 (1.5%) had deep venous thrombosis, and fewer than 5000 had renal vein thrombosis. The relative risk of pulmonary embolism comparing patients with the nephrotic syndrome to those who did not have it was 1.39, and the relative risk of deep venous thrombosis was 1.72. Among patients aged 18-39 years, the relative risk of deep venous thrombosis was 6.81. From 1991-2005, after venous ultrasound was generally available, the relative risk of deep venous thrombosis (all ages) was 1.77.

Conclusion

The nephrotic syndrome is a risk factor for venous thromboembolism. This is strikingly apparent in young adults. Renal vein thrombosis was uncommon. Therefore, pulmonary embolism, if it occurs, is likely to be due to deep venous thrombosis and not renal vein thrombosis.     

In-Hospital Risks and Management of Deep Venous Thrombosis According to Location of the Thrombus

BackgroundWhether deep venous thrombosis involving the pelvic veins or inferior vena cava is associated with higher in-hospital mortality or higher prevalence of in-hospital pulmonary embolism than proximal or distal lower extremity deep venous thrombosis is not known.MethodsThis was a retrospective cohort study based on administrative data from the Nationwide Inpatient Sample, 2016, 2017. Patients hospitalized with a primary diagnosis of deep venous thrombosis at known locations were identified by International Classification of Diseases-10-Clinical Modification codes.ResultsIn-hospital all-cause mortality with deep venous thrombosis involving the inferior vena cava in patients treated only with anticoagulants was 2.2% versus 0.8% with pelvic vein deep venous thrombosis (p<0.0001), 0.7% with proximal deep venous thrombosis (p<0.0001) and 0.2% with distal deep venous thrombosis (p<0.0001). Mortality with anticoagulants was similar with pelvic vein deep venous thrombosis compared with proximal lower extremity deep venous thrombosis, 0.8% versus 0.7% (p=0.39). Lower mortality was shown with pelvic vein deep venous thrombosis treated with thrombolytics than with anticoagulants, 0% versus 0.8% (p<0.0001). In-hospital pulmonary embolism occurred in 11% to 23%, irrespective of the site of deep venous thrombosis.ConclusionPatients with deep venous thrombosis involving the inferior vena cava had higher in-hospital mortality than patients with deep venous thrombosis at other locations. Pelvic vein deep venous thrombosis did not result in higher mortality or more in-hospital pulmonary embolism than proximal lower extremity deep venous thrombosis. The incidence of in-hospital pulmonary embolism was considerable with deep venous thrombosis at all sites.     

Arterial and venous thrombosis in rare congenital bleeding disorders: a critical review

A thorough review of the literature and of personal files has allowed the gathering of 81 patients with rare congenital bleeding disorders and thrombotic phenomena. Sixteen of these patients had congenital afibrinogenemia, eight involved factor V deficiency, 20 factor VII defects, 33 factor XI deficiencies and only one, a factor XIII defect. Altogether 42 patients showed arterial thrombosis (myocardial infarction [MI] in 28 cases; ischemic stroke in 4; arterial occlusion in 8; 2 patients with disseminated intravascular coagulation (DIC)). Ages varied between 13 and 74. Twenty-two patients were males and 16 females. In four cases, sex was not reported. There were three fatalities: two after a MI and one because of heart failure. With regard to venous thrombosis: 9 patients had pulmonary embolism, 15 patients had deep vein thrombosis, 9 patients had both pulmonary embolism and deep vein thrombosis; 1 patient had superficial vein thrombosis, whereas, 5 cases had an unusual site venous thrombosis (two portal systems, two cerebral sinuses, one inferior vena cava) for a total of 39 cases. Age varied between 3 and 86. In this case, 20 patients were males and 17 were females. In two cases, sex was not reported. There were three fatalities: two because of pulmonary embolism and one because of inferior vena cava thrombosis. The fact that thrombosis has never been described in patients with factor II or factor X seems to underscore the central antithrombotic role that these two factors have in the coagulation system.     

Unexpected high prevalence of silent pulmonary embolism in patients with deep venous thrombosis

In patients presenting with clinically suspected deep vein thrombosis, symptomatic pulmonary embolism is rarely apparent. To assess the prevalence of silent pulmonary embolism in outpatients with proven deep vein thrombosis but without symptoms of pulmonary embolism, perfusion ventilation lung scans were performed in 101 consecutive patients at presentation. Fifty-one percent of these patients had a high probability lung scan at the initiation of treatment. In comparison, in patients referred with suspected venous thrombosis, but who on subsequent objective testing did not have venous thrombosis (n = 44), the prevalence of a high probability-scan for pulmonary embolus was only 5 percent. At repeat lung scanning, performed after one week of anticoagulant treatment, complete to partial improvement was observed in 68 percent of the patients with initially abnormal scans. Lung-scan detected asymptomatic pulmonary embolism occurs frequently in patients presenting with symptomatic deep venous thrombosis, and the majority of these emboli showed significant to complete resolution within one week of anticoagulant treatment.     

Upper extremity deep vein thrombosis: a community-based perspective

Purpose

The purpose of this study was to examine the magnitude, risk factors, management strategies, and outcomes in a population-based investigation of patients with upper, as compared with lower, extremity deep vein thrombosis diagnosed in 1999.

Methods

The medical records of all residents from Worcester, Massachusetts (2000 census = 478,000) diagnosed with ICD-9 codes consistent with possible deep vein thrombosis at all Worcester hospitals during 1999 were reviewed and validated.

Results

The age-adjusted attack rate (per 100,000 population) of upper extremity deep vein thrombosis was 16 (95% confidence interval [CI], 13-20) compared with 91 (95% CI, 83-100) for lower extremity deep vein thrombosis. Patients with upper extremity deep vein thrombosis were significantly more likely to have undergone recent central line placement, a cardiac procedure, or an intensive care unit admission than patients with lower extremity deep vein thrombosis. Although short-term and 1-year recurrence rates of venous thromboembolism and all-cause mortality were not significantly different between patients with upper, versus lower, extremity deep vein thrombosis, patients with upper extremity deep vein thrombosis were less likely to have pulmonary embolism at presentation or in follow-up.

Conclusions

Patients with upper extremity deep vein thrombosis represent a clinically important patient population in the community setting. Risk factors, occurrence of pulmonary embolism, and timing and location of venous thromboembolism recurrence differ between patients with upper as compared with lower extremity deep vein thrombosis. These data suggest that strategies for prophylaxis and treatment of upper extremity deep vein thrombosis need further study and refinement.     

Sudden death due to pulmonary tumor embolism from testicular tumor: a case report

A 40-year-old man undergoing treatment for testicular tumor with para-aortic lymph node metastasis was transferred to our department because of pulmonary embolism. Thrombolysis therapy improved his respiratory state and deep venous thrombi disappeared. However, cardiopulmonary arrest occurred suddenly. Autopsy showed tumor cell invasion into the intima of the pulmonary artery and dissection with thrombosis. Thrombi had fresh components above organizing components. Sudden death due to pulmonary tumor embolism from testicular tumor is rare. In this case, the sudden death resulted from thrombosis in the pulmonary artery, not from emboli from the deep vein.     

Factors V leiden and II 20210A in patients with symptomatic pulmonary embolism and deep vein thrombosis

PURPOSE: Factor V Leiden and factor II 20210A are inherited disorders of the clotting system that occur frequently in patients with deep vein thrombosis. We conducted this study to determine whether these factors are also common in patients with pulmonary embolism. SUBJECTS AND METHODS: We determined the prevalence of factor V Leiden and factor II 20210A in 773 consecutive patients with objectively documented symptomatic deep vein thrombosis or symptomatic pulmonary embolism, or with a combination of these disorders. RESULTS: Isolated symptomatic deep vein thrombosis occurred in 345 patients; isolated symptomatic pulmonary embolism occurred in 236; and both anomalies occurred in 192. Factor V Leiden was present in 21 (9%) of the patients with isolated symptomatic pulmonary embolism, in 30 (16%) with both manifestations, and in 63 (18%) with isolated symptomatic deep vein thrombosis (P = 0.007). Factor V Leiden was more common among patients with deep vein thrombosis (odds ratio [OR] = 2.1; 95% confidence interval [CI]: 1.2 to 3.7; P = 0.006) or both pulmonary embolism and deep vein thrombosis (OR = 1.8; 95% CI: 1.0 to 3.3; P = 0.07) than among patients with isolated pulmonary embolism. Factor V Leiden was less common in massive pulmonary embolism (5% [7 of 127]) than in submassive pulmonary embolism (13% [21 of 155], P = 0.03). We found no significant difference in the prevalence of factor II 20210A among the three groups. CONCLUSION: Factors V Leiden and II 20210A vary in prevalence among patients with pulmonary embolism and deep vein thrombosis, suggesting that the risk of pulmonary embolization may vary among patients who have different causes of venous thromboses.     

Very long-term outcome of 68 vena cava filters percutaneously implanted

Between January 1987 and December 1991, 68 consecutive patients aged 71.5 +/- 12.0 years underwent percutaneous implantation of a vena caval filter, mainly the LGM (N = 64). Fifty seven patients had pulmonary embolism, 61 had deep vein thrombosis of the lower limbs. The average follow-up interval was 4.9 +/- 3.3 years (7.0 +/- 2.7 years for the patients still alive). The follow-up included a telephonic enquiry to determine the date and cause of death, recurrent deep vein thrombosis and/or pulmonary embolism; surviving patients underwent clinical examination, plain abdominal X-ray with a lateral decubitus view and duplex ultrasonography of the lower limb veins to assess the patency of the filter. Fifty three per cent of the patients died. Four predictive factors for mortality were identified: a contra-indication to anticoagulant therapy, chronic post-embolic cor pulmonale, an indication of prophylactic implantation in the elderly and the presence of underlying malignant disease. There were 5.8% recurrences of pulmonary embolism, 26.1% of lower limb deep vein thrombosis and 25% of filter thrombosis. The only predictive factor of thrombosis was a proximal venous thrombus and was associated in 50% of filter thrombosis. Seventy per cent of the plain abdominal X-rays were abnormal with 9 displacements. 9 migrations and 10 closures of the filters. There was a significant correlation between closure on plain abdominal X-ray and caval thrombosis and between recurrent deep vein thrombosis and caval thrombosis. The frequency of long-term complications after implantation of a caval filter in this study suggests that interruption of the vena cava should be reserved for the only validated indications in the presence of a formal contra-indication to or failure of anticoagulant therapy. Other indications require evaluation with prospective randomised trials.     

A comparison of three rapid D-dimer methods for the diagnosis of venous thromboembolism

We compared three rapid D-dimer methods for the diagnosis of venous thromboembolism. Patients presenting to four teaching hospitals with the possible diagnosis of deep vein thrombosis or pulmonary embolism were investigated with a combination of clinical likelihood, D-dimer (SimpliRED) and initial non-invasive testing. Patients were assigned as being positive or negative for deep vein thrombosis or pulmonary embolism based on their three-month outcome and initial test results. The three D-dimer methods compared were: (a) Accuclot D-dimer (b) IL-Test D-dimer (c) SimpliRED D-dimer. Of 993 patients, 141 had objectively confirmed deep vein thrombosis or pulmonary embolism. The sensitivity of SimpliRED, Accuclot and IL-Test were 79, 90 and 87% respectively. All three D-dimer tests gave similar negative predictive values. The SimpliRED D-dimer was found to be less sensitive than the Accuclot or IL-Test. When combined with pre-test probability all three methods are probably acceptable for use in the diagnosis of venous thromboembolism.     

Utilization of partition analysis to evaluate the incidence on deep vein thrombosis following esophagectomy

Background

We performed a retrospective observational study to examine the involvement of suspicious factors and causes of deep vein thrombosis using cases of esophagectomy that were done to treat esophageal carcinoma.

Methods

The 144 patients received esophagectomy in Okayama University Hospital from January 2005 to June 2007. All patients had an enhanced CT or an ultrasound examination after their operations. The incidence of deep vein thrombosis was then determined. For cases that found deep vein thrombosis, the anticoagulant treatment was strengthened. When the thrombosis was already so large to be seen in the inferior vena cava, the IVC filter was left to prevent a pulmonary embolism. Using JMP5.0.1 statistical analysis software, we analyzed the relationship between various clinical factors and the incidence of deep vein thrombosis.

Results

Using JMP5.0.1, factors causing deep vein thrombosis were analyzed and partitioning was done. The most significant risk factor causing deep vein thrombosis is leaving the central venous catheter inserted into the inguinal femoral area. Logistic analysis also showed that only the catheter if inserted from the inguinal femoral area, was significantly related to cause deep vein thrombosis (p < 0.0055). No other factor was a significant risk to cause deep vein thrombosis.

Conclusions

We analyzed the relationship between suspicious factors and the causes of deep vein thrombosis in cases of esophagectomy. The most relevant factors were inserting the central venous catheter from the inguinal femoral route. This evidence can be applied to both pre-operative and postoperative management to prevent deep vein thrombosis.     

Comparison of fibrinolytic treatment with interruption of the inferior caval vein in the prevention of pulmonary embolism

The procedure of interruption of the inferior caval vein is designed to prevent pulmonary embolism, but its effectiveness has yet to be compared with thrombolytic therapy. Sixty patients hospitalized for pulmonary embolism and proximal deep vein thrombosis were divided into two groups of 31 and 29 patients, respectively. The patients were selected because of persistent venous thrombosis in the inferior caval, iliac or femoral veins. The patients in the first group (mean age 53.2 years) were treated by interruption of the inferior caval vein. The second group of patients (mean age 57) received only fibrinolytic treatment. From those patients having caval venous interruption due to peri-operative myocardial infarction 1 died and 3 others presented pulmonary embolism (massive in two cases). No patients treated by fibrinolysis suffered from pulmonary embolism. Five patients died of cancer, 2 having had caval interruption, as opposed to only 2 having fibrinolysis. Eight patients undergoing surgery had a severe functional handicap. This study demonstrated a high recurrence of pulmonary embolism in patients with persistent venous thrombosis who were treated by interruption of the inferior caval vein. These patients also had a high morbidity. Fibrinolytic treatment (even in the presence of persistent venous thrombosis) appeared to be more effective in avoiding recurrence of pulmonary embolism.     

Clinical assessment of vascular thrombosis using indium-111 platelet scintigraphy

The authors reviewed the clinical value of platelet scintigraphy by using autologous platelets labeled with indium-111-oxine to detect thrombotic activity at vascular thrombosis sites. Thirty-nine patients with deep vein thrombosis, 28 with arteriosclerosis obliterans, and 10 with pulmonary embolism were the subjects of this study. Platelet accumulation on scintigrams had a tendency to correlate with aggravation of acute thrombotic symptoms in deep vein thrombosis and arteriosclerosis obliterans. In addition, appropriate thrombolytic and anticoagulant therapy resulted in reduced platelet accumulation in conjunction with improvement of acute symptoms. On the other hand, this type of scintigraphy was not so sensitive for assessment of pulmonary embolism. Platelet scintigraphy could facilitate the assessment of thrombotic activity and might be useful for determining the optimal indication of thrombolytic and anticoagulant therapy for acute vascular thrombosis.     

Prevention of venous thromboembolism

The aim of prophylaxis in venous thromboembolism is firstly to prevent fatal pulmonary embolism and secondly to reduce the morbidity associated with deep vein thrombosis and the post-phlebitic limb. Particularly high-risk groups are identifiable and include those over 60 years of age undergoing major surgery, patients with malignancy and those undergoing hip operations. Low-dose subcutaneous heparin (5000 U s.c. commenced two hours preoperatively and continued eight to twelve hourly until the patient is fully mobile) is unequivocally effective in preventing deep vein thrombosis in medical and surgical patients and, most importantly, significantly reduces the incidence of fatal postoperative pulmonary embolism and total mortality. Furthermore, in established deep vein thrombosis, low-dose heparin limits proximal clot propagation, which is the prelude to pulmonary embolism. Despite this, surveys have demonstrated an alarming deficiency amongst clinicians in the application of measures to prevent venous thromboembolism. Heparin prophylaxis carries a small risk of increased bleeding complications, mostly evidenced by the frequency of wound haematoma rather than major haemorrhage. Low molecular heparin fragments (e.g. Fragmin, Choay, Enoxaprin) are now emerging as useful alternative agents, having the advantage of once daily administration and yet providing similar efficacy in the prevention of deep vein thrombosis. However, protection against fatal pulmonary embolism has yet to be demonstrated. Mechanical methods of prophylaxis designed to counteract venous stasis, such as graduated elastic compression stockings, are also beneficial in protection against deep vein thrombosis but by themselves do not achieve such consistently good prophylaxis as low-dose heparin. However, clinical trials with combinations of mechanical methods and low-dose heparin indicate that this may be the optimum approach to very high-risk patients. In the presence of established acute deep vein thrombosis, anticoagulant therapy is the mainstay in preventing pulmonary embolism. Vena caval interruption procedures should be reserved for patients in whom anticoagulation is contraindicated or for those who develop recurrent pulmonary embolism despite adequate anticoagulation.     

Inherited thrombophilic risk factors in a large cohort of individuals referred to Italian thrombophilia centers: distinct roles in different clinical settings.

BACKGROUND AND OBJECTIVES: Despite inherited thrombophilic risk factors being strongly associated with vein thrombosis, decisions on whether to screen subjects for these factors vary in different clinical settings. DESIGN AND METHODS: We calculated the prevalence of inherited thrombophilic risk factors in a large cohort of patients (n=1,238) with different clinical manifestations of vein thromboembolism. In the present cohort, screening for inherited thrombophilia was worthwhile among patients who developed vein thrombosis of the leg or cerebral vein thrombosis. Carriers of FV Leiden or FII A(20210) mutation more frequently had had deep vein thrombosis of the leg (OR: 4.35; 95% CI: 3.39-5.60), superficial vein thrombosis (OR: 3.34; 95% CI: 2.06-5.41), or cerebral vein thrombosis (OR: 2.77; 95% CI: 1.10-6.96). RESULTS: The screening program appeared to have a limited relevance in patients with isolated pulmonary embolism (OR: 2.13; 95% CI: 1.28-3.54), or mesenteric vein thrombosis (OR: 2.05; 95% CI: 1.22-3.44). INTERPRETATION AND CONCLUSIONS: The lack of association with inherited thrombophilia does not justify routine screening of patients with thrombosis of the upper extremities or with retinal vein thrombosis.     

Diagnosis of venous thromboembolism: factors determining individual patient probabilities of deep vein thrombosis or pulmonary embolism

The diagnosis of venous thromboembolism, which comprises deep vein thrombosis and pulmonary embolism, remains challenging. Combining pretest probability of disease with the results of noninvasive testing, such as ventilation-perfusion lung scan and duplex ultrasound, can avoid costly and invasive testing with pulmonary angiography and contrast venography in most patients. Techniques to estimate the pretest probability of deep vein thrombosis and pulmonary embolism are described.     

Partial interruption of the inferior vena cava using a percutaneous endovenous filter

Partial interruption of the inferior vena cava (IVCI) by a percutaneous endovenous filter (Günther filter n = 65, LEM filter n = 36) was undertaken in 100 patients with an average of 72 +/- 11 years for recent deep vein thrombosis. The indications were: contraindications to anticoagulant therapy (36.5%); recurrent pulmonary embolism (12%); threatening venous thrombosis with a previous embolic episode (12%); caval thrombosis (15.7%); prophylactic, with no previous pulmonary embolism (23.8%). The filters were evaluated at short and mid term. There were no technical problems. The mortality rate was 17.5%, one death being probably due to recurrent pulmonary embolism. No other recurrences of pulmonary embolism were observed, indicating an efficacy of 99 per cent. The early patency rate was 96.5%, there being no difference between the two filters used, independent of the initial site of venous thrombosis, of distal migration of the filter and associated medical treatment (anticoagulation). Distal migration was observed in 76% of IVCI by the Günther filter and 48.5% by the LEM filter (p less than 0.001); tilting was observed in 7.4% of Günther and 3% of LEM filters. Five LEM filters were incompletely opened. The IVC was transfixed by 3 Günther filters. One Günther filter had fractured spokes. There were 12 recurrences of lower limb deep vein thrombosis and 16 post-deep vein thrombosis complications were recorded. These percutaneous endovenous filters are similar to the Kimray Greenfield filter with respect to efficacy and permeability although the follow-up was relatively short. The advantages of these percutaneous filters are the facility, innocuity and rapidity of their insertion with, however, a higher incidence of distal migration.     

Validation of a clinical guideline on prevention of venous thromboembolism in medical inpatients: a before-and-after study with systematic ultrasound examination

BACKGROUND: Clinical practice guidelines on prevention of venous thromboembolism in medical inpatients have been implemented in various settings, although few studies have assessed their impact on venous thromboembolism events. OBJECTIVE: To determine whether the implementation of a locally developed guideline is followed by changes in the rate of deep vein thrombosis. DESIGN: A before-and-after study consisting in two "1-day" cross-sectional studies. SETTING: Thirteen adult medical wards in a teaching hospital in France. SUBJECTS: All the patients hospitalized on the day of the cross-sectional study. INTERVENTION: A clinical guideline integrating scientific evidence and data on target medical providers' practices was developed by a local expert panel and implemented through a multifaceted intervention. MEASUREMENTS: Prevalence of deep vein thrombosis detected by systematic ultrasound examination. RESULTS: The study included 338 patients in the preintervention sample and 340 in the postintervention sample. The prevalence of deep vein thrombosis decreased from 9.5% (95% CI, 6.6-13.1) in the preintervention sample to 3.2% (95% CI, 1.6-5.7) in the postintervention sample (P < 0.01). The decrease in the rate of thrombosis involved all deep veins of the lower limbs and remained significant after adjustment for risk factors (adjusted odds ratio = 0.47, 95% CI, 0.32-0.70). No additional cases of pulmonary embolism or deep vein thrombosis were reported either on the day of the study or in the following 2 days. CONCLUSIONS: Active implementation of a clinical practice guideline directed at medical providers (doctors, nurses and physical therapists) can be followed by a significant decrease in prevalence of deep vein thrombosis.     

Multiple pulmonary emboli with pulmonary hypertension caused by effort thrombosis and effective balloon venoplasty of the subclavian vein

A 36-year-old woman with effort thrombosis of the subclavian vein associated with multiple pulmonary emboli was successfully treated with local thrombolysis of the subclavian vein using a pulse-spray catheter and systemic anticoagulation. Balloon venoplasty of the residual stenosis of subclavian vein was carried out and in follow-up venography 6 months later, there was no restenosis, and the patient has been asymptomatic for 12 months. Pulmonary embolism is not a rare complication of upper extremity deep vein thrombosis and should be managed as aggressively as lower extremity deep vein thrombosis.     

Deep venous thrombosis and pulmonary thromboembolism associated with a huge uterine myoma--a case report

A 51-year-old woman with a large uterine myoma suffered from acute pulmonary thromboembolism. Venography revealed thrombosis in the right common iliac vein and almost complete obstruction of the left common iliac vein. The ascending lumbar vein showed collateral drainage. Treatment was initiated with continuous intravenous heparin sodium, and a Greenfield filter was inserted to prevent the extension of the pulmonary embolism during and after hysterectomy. After a total hysterectomy, venography revealed restoration of patency in the bilateral common iliac veins, and no flow was seen in the ascending lumbar vein. Thorough clinical examinations failed to identify any other prothrombotic conditions. These results suggest that a large uterine myoma compressed veins in the pelvis, and the resulting impaired blood flow caused deep venous thrombosis and pulmonary thromboembolism.