Noninvasive imaging of the lower extremity for deep venous thrombosis

Noninvasive imaging for LE DVT has advanced remarkably in the past decade. Currently, IPG and ultrasound techniques (RTU and DS) have been proven to be quick, accurate, relatively inexpensive, and widely available methods for detecting proximal LE DVT and can be used as the initial diagnostic studies in many settings. Color-flow Doppler ultrasound studies may be more accurate than other ultrasound techniques in diagnosing calf DVT and in differentiating acute from chronic LE DVTs, though this bears further review. Many concerns remain regarding noninvasive LE DVT imaging, including:

Serial limited versus single complete compression ultrasonography for the diagnosis of lower extremity deep vein thrombosis

The diagnostic approach to deep vein thrombosis (DVT) has evolved during the last 3 decades. Contrast venography has been replaced by noninvasive tests. Compression ultrasonography (CUS) is currently the most widely used diagnostic test. Whereas CUS has a high accuracy for proximal DVT (thrombosis of the popliteal and more proximal veins), it has been shown to lack sensitivity and specificity for distal DVT. Ultrasonography can either be limited to the proximal veins and repeated within 1 week (serial limited CUS) or extended to both proximal and distal veins and performed on one occasion (single complete CUS). Both strategies are reliable diagnostic options for the management of patients with suspected DVT. The main limitation of proximal CUS is the need to repeat the test once in patients with initial negative findings. Conversely, complete CUS detects many distal DVTs for which systematic anticoagulation therapy is debatable and exposes patients to potentially unnecessary anticoagulation. Incorporation of D-dimer testing and clinical pretest probability assessment in the diagnostic algorithm is beneficial because it allows excluding DVT without the need for diagnostic imaging in about a third of patients.     

Criteria for outpatient management of proximal lower extremity deep venous thrombosis

STUDY OBJECTIVES: To develop and to evaluate selection criteria for outpatient management of deep venous thrombosis (DVT). DESIGN: We developed outpatient treatment eligibility criteria that incorporated demographic and clinical data. We aimed to exclude patients at high risk for bleeding or recurrent clotting, as well as those with pulmonary embolism, limited cardiopulmonary reserve, or need for hospitalization due to another illness. Then, we retrospectively applied the criteria to hospitalized patients with newly diagnosed proximal lower extremity DVT to determine the fraction of patients eligible for outpatient therapy; patients were classified as eligible, possibly eligible, or ineligible for home treatment based on the selection criteria. SETTING: University hospital. PATIENTS: One hundred ninety-five hospitalized patients diagnosed as having proximal lower extremity DVT by duplex ultrasound over a 1-year period. MEASUREMENTS: Frequency of complications during initial DVT therapy, including major bleeding, symptomatic thromboembolism, and death. RESULTS: Eighteen (9%) patients were classified as eligible, and 18 (9%) were classified as possibly eligible for outpatient therapy. None of these patients developed complications. Of the 159 (82%) patients classified as ineligible, 13 (8%; 95% confidence interval [CI], 4 to 12%) died or developed serious complications. Therefore, the eligibility criteria had a sensitivity of 100% (95% CI, 92 to 100%) and a negative predictive value of 100% (95% CI, 92 to 100%) for predicting serious complications. CONCLUSIONS: Specific eligibility criteria may identify a subset of patients with acute DVT who can be treated safely at home.     

下肢深静脉血栓形成62例综合治疗分析

目的探讨综合治疗下肢深静脉血栓形成的临床效果。方法对62例下肢深静脉血栓形成患者采取下腔静脉滤器置人、手术取栓、溶栓、抗凝、祛聚、穿减压袜等综合治疗。结果治愈43例(69.35%),好转15例(24.19%),无效4例(6.45%),无死亡病例。总有效率为93.5%。结论综合治疗下肢深静脉血栓形成效果好,可缩短病程,值得推广应用。     

Upper extremity deep venous thrombosis

PURPOSE: To determine the prevalence of symptomatic upper extremity deep venous thrombosis (DVT) and its association with symptomatic acute pulmonary embolism (PE) in a community teaching hospital. METHODS: The prevalence of symptomatic upper extremity DVT was evaluated retrospectively at a community teaching hospital during the 2-year period between July 1, 1998, and June 30, 2000. Patients were identified by International Classification of Disease, ninth revision, clinical modification, discharge codes and a review of the records of all compression Doppler ultrasonograms, venograms of the upper extremities, and magnetic resonance angiograms of the upper extremities. RESULTS: Symptomatic upper extremity DVT was diagnosed in 65 of 44,136 patients of all ages (0.15%) [or 64 of 34,567 adult patients >or= 20 years of age; 0.19%]. In seven patients, the upper extremity DVT was shown by venography to extend proximally to the brachiocephalic vein. Among these, the DVT extended to the superior vena cava in two. All of the patients received anticoagulant therapy for upper extremity DVT. No patients developed symptomatic PE. Central lines at the site of the upper extremity DVT were inserted in 39 of 65 patients (60%). Cancer was diagnosed in 30 of 65 patients (46%), 23 cancer patients also had central lines, and 19 patients (29%) had upper extremity DVT with no apparent cause. All patients had swelling of the upper extremities. Erythema over the affected site was present in four patients (6%). Pain was present in 26 patients (40%), although some discomfort due to swelling was present in all patients. CONCLUSION: Symptomatic upper extremity DVT is not uncommon in hospitalized patients. Symptomatic PE resulting from upper extremity DVT was not observed in these patients, all of whom were treated with anticoagulants.     

Upper extremity deep venous thrombosis

Upper extremity deep venous thrombosis is a serious disease entity which, based on the pathogenesis and in view of the individual patient's prognosis, must be divided into a primary and a secondary form. Primary upper extremity deep venous thrombosis is, when related to effort, a rather benign disease with excellent prognosis quoad vitam, carrying only a minor potential of developing disabling post-thrombotic syndrome. If primary upper extremity deep venous thrombosis occurs without any obvious cause, screening for underlying malignancy is recommended. Secondary upper extremity deep venous thrombosis typically occurs in older patients with severe comorbidities, mainly related to indwelling central venous catheters and cancer. As a consequence of the underlying diseases, prognosis of secondary upper extremity deep venous thrombosis is poor. Despite a lack of high-quality validation data, ultrasonography is regarded the first-line imaging technique, since it is a non-invasive method without exposure to radiation. In case of a non-diagnostic result of ultrasonography, other imaging modalities such as magnetic resonance imaging and computed tomography may be applied. Regardless of the etiology, the cornerstone of therapy is anticoagulant treatment with low molecular weight heparin or unfractionated heparin and vitamin K antagonists in order to prevent thrombus progression and pulmonary embolism. Owing to a lack of evidence, the optimal duration of anticoagulant treatment remains unclear. The additional benefit of compression therapy as well as of more aggressive therapeutic approaches such as thrombolysis, angioplasty and surgical decompression of the thoracic outlet needs to be investigated in randomized trials.     

Upper extremity deep venous thrombosis

Upper extremity deep venous thrombosis (UEDVT) makes up approximately 1-4% of all episodes of deep venous thrombosis (DVT). Risk factors for UEDVT include central venous catheterization, strenuous upper extremity exercise or anatomic abnormalities causing venous compression, inherited thrombophilia, and acquired hypercoagulable states including pregnancy, oral contraceptive use, and cancer. Unexplained or recurrent UEDVT should prompt a search for inherited hypercoagulable states or underlying malignancy. Clinical presentations include arm, neck, and shoulder pain; edema; skin discoloration; tenderness; and venous distension. Because UEDVT is frequently asymptomatic until complications ensue, a high index of suspicion is required for patients with one or more risk factors for thrombosis. Pulmonary embolism and post-thrombotic syndrome are the most common sequelae of UEDVT. Early detection and treatment of UEDVT decrease complications, morbidity, and mortality. Compressive ultrasonography is an effective and economical means of confirming the clinical diagnosis in most patients. Traditional anticoagulant therapy of UEDVT is giving way to a multimodal approach involving transcatheter thrombolytic therapy followed by a minimum of 3 months of warfarin sodium anticoagulant therapy, venous decompression as needed, and balloon angioplasty with stenting for treatment of residual stricture. Low-dose anticoagulant therapy can safely and effectively mitigate the increased risk of UEDVT associated with the use of central venous catheters.     

Upper extremity deep venous thrombosis

About 10% of all episodes of venous thrombosis are due to upper extremity deep vein thrombosis (UEDVT). Associated risk factors are indwelling central venous catheters, cancer, and coagulation defects; 20% of the episodes are unexplained. The onset of UEDVT is usually heralded by complaints such as arm swelling and pain, but may also be completely asymptomatic, especially in carriers of central venous lines. Objective confirmation is mandatory prior to instituting anticoagulation because the clinical diagnosis is unreliable; ultrasound-based methods represent the preferred diagnostic approach. Prophylaxis with low-dose heparin or low-dose warfarin may be used, especially in carriers of central venous catheters, although its efficacy is still uncertain. Unfractionated or low molecular weight heparins followed by oral anticoagulants should be regarded as the treatment of choice, whereas thrombolysis and surgery may be indicated in selected cases. Up to one third of the patients develop pulmonary embolism that may be fatal; postthrombotic syndrome and recurrent thromboembolism are also frequent complications. UEDVT should no longer be regarded as a rare and benign disease, as reported previously.     

老年人下肢深静脉血栓形成的临床特点

目的 总结老年人下肢静脉深血栓形成(DVT)的临床特点.方法 分析180例老年人DVT的发病情况、危险因素、并发症和疗效,并与同期收治的144例非老年人DVT病例资料对比.结果 老年人DVT以60～69岁年龄段最多[91例(50.5%)],其次为70～79岁[73例(40.5%)].前5位危险因素是大手术后(27.8%)、恶性肿瘤(15.0%)、外伤骨折(7.8%)、脑血管病后遗症(7.2%)、长期卧床(5.0%).并存Cockett综合征43例(49.4%),其中髂总静脉闭塞6例(14.0%)、狭窄>50%21例(48.8%)、狭窄<50%16例(37.2%).急性期DVT的取栓术疗效优于系统溶栓,非急性期两种方法 疗效差异无统计学意义.老年人与非老年人的近、远期疗效差异无统计学意义.结论 老年人易患DVT,恶性肿瘤和脑血管病后遗症是与老年人DVT相关的危险因素.对于老年人急性期DVT,取栓术的近、远期疗效优于系统溶栓.     

AngioJet机械吸栓装置在急性下肢深静脉血栓形成中的应用

［摘要］　目的　通过对比分析导管接触性溶栓（CDT）与AngioJet机械吸栓术在急性下肢深静脉血栓形成的治疗效果。方法　回顾性分析2018-01～2019-11安徽医科大学第二附属医院血管外科收治的34例经介入手术治疗的急性下肢深静脉血栓形成患者的临床资料,其中18例行CDT治疗（CDT组）,16例行AngioJet机械吸栓治疗（AngioJet组）。比较两组患者手术前后D-二聚体（D-D）峰值及纤维蛋白原值、术后下肢消肿率及血栓清除率。结果　34例患者均顺利完成手术。CDT组即刻血栓清除率、消肿率均低于AngioJet组,差异有统计学意义(P<0.05)。术后CDT组的D-D峰值及尿激酶用量均高于AngioJet组,差异有统计学意义(P<0.05)。结论　AngioJet机械吸栓装置在急性下肢深静脉血栓形成治疗中具有更高的血栓清除率及安全性,对指导临床应用有一定的意义。     

替罗非班在下肢深静脉血栓介入治疗中的应用

目的:探讨下肢深静脉血栓介入治疗中形成急性血栓,应用新型抗血小板药物替罗非班的临床价值。方法:在下腔静脉滤器保护下,急性下肢深静脉血栓形成患者行介入综合治疗,术中6例患者均在血流再通后发生静脉内急性新鲜血栓,静脉推注替罗非班负荷量8-10 ml,并8 ml／h维持48 h。结果:静脉内推注替罗非班10-30 min后重复造影显示血栓消失,术后所有患者症状明显改善,预后良好,无严重并发症发生。结论:替罗非班对深静脉血栓介入治疗过程中形成急性血栓有良好的疗效。     

Efficacy of modified pressure cuff for thrombolytic treatment on lower extremity deep venous thrombosis

To compare the effectiveness and patient comfort between two methods that block superficial venous blood flow during the thrombolytic treatment of lower extremity deep venous thrombosis (DVT) to provide evidence that informs clinical choice.One hundred twenty patients with lower extremity DVT were randomly divided into sphygmomanometer (group A, n = 40), tourniquet (group B, n = 40), and control group (no blocking, n = 40). All the patients were treated with a daily dosage of urokinase using a dial sphygmomanometer cuff and tourniquet to block lower extremity superficial vein blood flow. The pressure of the dial sphygmomanometer blocking lower extremity superficial vein blood flow was measured during lower extremity venography. Leg swelling reduction rate, venous patency, thrombus removal rate, and average comfort index were observed during the blocking process.The average pressure value for group A was 70  ± 10 mm Hg. The differences in the swelling reduction rate and venous patency were significant between the groups. Comparing the two groups at different time points, the average thrombus clearance rate of group A was higher than that of group B and control group. The leg pain scores of group A were lower than those of group B and control group. The postoperative comfort ratio of group A was higher than that of group B, and the proportion of severe discomfort in group A was lower than that in group B.Compared with the tourniquet, using a dial sphygmomanometer cuff to block lower extremity superficial vein blood flow achieved a better thrombolytic effect on DVT and provided higher patient comfort during treatment.     

经皮胭静脉穿刺诊治下肢深静脉血栓39例临床分析

目的探讨经皮胭静脉血流顺向性介入治疗下肢深静脉血栓的可行性。方法对39例下肢深静脉血栓患者经健侧股静脉置入下腔静脉滤器后，穿刺患侧胭静脉，以胭静脉为人路，行血管内溶栓、血栓消融器消融和（或）球囊成形及腔内支架置人术等治疗。结果经皮胭静脉穿刺均获成功，无严重并发症发生。结论以患侧胭静脉为人路，血流顺行性介入治疗下肢深静脉血栓操作简便，是一种安全有效的方法。     

Real-time ultrasound in the diagnosis of acute deep venous thrombosis of the lower extremity

One hundred twenty-six patients with clinically suspected acute deep venous thrombosis of the lower extremity (DVT) were examined comparatively with ultrasound and venography. In total, 174 lower extremity venograms were obtained. Ultrasonic examinations were performed on patients in the supine position. The venous segments were evaluated almost exclusively with transversal scanning. In the thigh, the only criterion for DVT was the reduced or absent compressibility of the venous lumen when gently compressed with the transducer. In the calf, normal unobstructed veins can usually not be viewed in the supine patient, whereas thrombotic veins appear as sonolucent, incompressible channels. Eight-three of the 174 lower extremity venograms were positive for DVT. In the majority of cases (53 of 83) the thrombotic process had involved two or more segments in combination. The sites of involvement of the different venous segments were distributed as follows: 24 occlusions of the common femoral vein, 52 of the superficial femoral vein, 56 of the popliteal vein, and 71 of the calf veins. Ultrasound had a sensitivity of 100% for thrombosis of the common femoral vein, 96% for the superficial femoral veins, 98% for the popliteal vein, and 93% for the calf veins. For the entire lower extremity, in regard to the diagnosis of thrombosis, the overall sensitivity was 95%. In 90% the extension of the occlusion was foreseen correctly. In no cases were false-positive results reported. Thus the overall specificity was 100%. The authors conclude that real-time ultrasound is a highly accurate method for the diagnosis of DVT of the lower extremity. It is the only indirect method capable of evaluating the venous system of the thigh, as well as that of the calf, with high accuracy. It should be the first choice of diagnostic imaging method in the diagnosis of deep venous thrombosis of the lower extremity.     

经皮腘静脉穿刺诊治下肢深静脉血栓39例临床分析

目的探讨经皮腘静脉血流顺向性介入治疗下肢深静脉血栓的可行性。方法对39例下肢深静脉血栓患者经健侧股静脉置入下腔静脉滤器后,穿刺患侧腘静脉,以腘静脉为入路,行血管内溶栓、血栓消融器消融和(或)球囊成形及腔内支架置人术等治疗。结果经皮腘静脉穿刺均获成功,无严重并发症发生。结论以患侧腘静脉为入路,血流顺行性介入治疗下肢深静脉血栓操作简便,是一种安全有效的方法。     

Thrombophilia differences in splanchnic vein thrombosis and lower extremity deep venous thrombosis in North America

Background

The utility of thrombophilia testing in patients with splanchnic vein thrombosis (SpVT) has not previously been rigorously evaluated. The purpose of this study was to characterize differences in the prevalence of thrombophilia in patients with SpVT involving portal (PVT), mesenteric (MVT), splenic (SVT), or hepatic (HVT) veins in isolation or with multisegmental (M-SpVT) involvement compared to patients with lower extremity deep vein thrombosis (DVT).

Methods

An inception cohort of patients with incident SpVT was identified for whom comprehensive thrombophilia testing was performed between 1995 and 2005 and compared to DVT controls.

Results

341 patients with SpVT (mean age 50 ± 16 years, 53 % women) including isolated PVT (n = 112), MVT (n = 67), HVT (n = 22), SVT (n = 11), and M-SpVT (n = 129) involvement and 3621 DVT controls (mean age 55 ± 16 years, 56 % women) had comprehensive thrombophilia testing. The prevalence of abnormal results was similar for SpVT (24.6 %) and DVT (25.9 %) patients. “Strong” thrombophilias were more prevalent among SpVT patients (12.3 vs. 8.5 %, p = 0.0168). Patients with splenic (45.5 %) and mesenteric (41.8 %) thrombosis had the highest thrombophilia prevalence. Protein S deficiency was more common in SpVT patients (3.5 vs. 0.9 %, p < 0.001). In contrast, FV Leiden was more prevalent among DVT patients (15.8 vs. 10.9 %, p = 0.0497).

Conclusion

The prevalence of selected thrombophilia factors differ comparing SpVT and DVT patients. The prevalence is particularly high for patients with splenic and mesenteric vein thrombosis. Whereby the finding of strong thrombophilia impacts duration of anticoagulant therapy, such testing is warranted in the evaluation of patients with unprovoked SpVT.     

老年下肢深静脉血栓患者D-二聚体的临界值研究

目的探讨老年患者血浆D-二聚体(DD)水平预测下肢深静脉血栓(DVT)的临界值。方法选择年龄≥60岁的住院患者394例,根据是否合并DVT,分为非DVT组235例和DVT组159例,DVT组60～79岁81例和≥80岁78例。住院期间,每隔1～2周进行血浆DD检查,对DD≥0.5mg/L的患者,即行下肢静脉血管超声检查,每隔3～5d进行超声复查,且DD检测时间缩短为每隔3～5d。结果与非DVT组比较,DVT组DD水平明显升高(P<0.01)。≥80岁患者DD水平较60～79岁患者明显升高(P<0.01);2个年龄段患者DD各临界值诊断下肢DVT的敏感性、特异性、阳性预测值及阴性预测值差异较大。结论将60～79岁患者预测下肢DVT的DD临界值定为0.5mg/L,≥80岁患者DD临界值定为2.0mg/L有临床指导意义。     

经导管接触溶栓治疗下肢深静脉血栓患者的临床效果观察

目的探讨经导管接触溶栓治疗下肢深静脉血栓患者的临床效果。方法选取该院2014-06~2016-06收治的下肢深静脉血栓患者82例,按照随机数字表法分为观察组(41例)和对照组(41例)。观察组采用经导管接触溶栓治疗,对照组采用单纯静脉药物溶栓治疗。比较两组治疗疗效、下肢消肿时间、住院时间及肢体消肿率。结果观察组疗效优于对照组,差异有统计学意义(P0.05);观察组下肢消肿时间及住院时间短于对照组,差异有统计学意义(P0.01);两组治疗后周径缩小(P0.05);且观察组治疗后周径小于对照组(P0.01);观察组肢体消肿率高于对照组,差异有统计学意义(P0.01)。结论经导管接触溶栓治疗下肢深静脉血栓患者临床效果显著,可明显提高肢体消肿率,值得进一步研究。