Superficial venous thrombosis of the lower extremities co-existing with deep venous thrombosis. A phlebographic study on 57 cases

The incidence of deep venous thrombosis (DVT) coexistent in patients suffering from superficial venous thrombosis (SVT) has not been well documented. In a series of 57 consecutive patients with SVT of the lower extremities treated in our Department in the last five years without any obvious clinical signs of co-existing DVT, an ascending phlebographic study was performed. Co-existent DVT was disclosed in 19.6% of the patients. There was no correlation between the location or the length of thrombus and the co-existence of DVT. Patients in whom SVT developed in existing varicose veins were younger in age and the incidence of co-existence of DVT was lower. Our findings show that SVT does not always have a benign course. The disclosure of a high incidence of co-existing DVT in our series suggests the necessity of the examination of the deep venous system in all the cases of SVT by using ultrasonic technics, triplex and preferably of the ascending phlebography. The disclosure of DVT in those cases makes the application of anticoagulant treatment mandatory.     

Superficial venous thrombosis of the lower limbs: prospective analysis in 100 patients

OBJECTIVES: Our objectives were first to estimate the potential gravity of superficial venous thrombosis (SVT) of the lower limbs by determining the frequency of associated deep venous thrombosis (DVT), pulmonary embolism (PE) and extensions of the junction or a perforating vein and second to identify factors of risk (neoplasia, thrombophilia, connective tissue disease, thromboembolic events). METHOD: We conducted a prospective study in 100 cases of SVT in 88 patients with varicose veins (VV) and 12 patients without varicose veins (NVV). RESULTS: Superficial venous thrombosis was identified in 32 cases (32%): muscle vein in 23 (gastrocnemius, solesu), popliteo-femoro-iliac system in 5, and posterior tibial or fibular vein in 4. In 17 cases (17) the SVT extended to deep veins at distant localizations in 15 (15%). Pulmonary embolism was suspected clinically in 10 cases (10%) and confirmed in 3 (3%). An extension to the saphenous junction was observed in 17 cases (17%) and the thrombus migrated into a deep vein in 7. There were 6 cases of a unique extension to a perforating vein. Search for etiology was conducted in 86 cases: 64 were negative (74.4%), there was a neoplasia context in 5 (6%) and a hemostasis disorder in 17 (19.8%) including 6/12 (50%) in the NVV group and 11/74 (15%) in the VV group. CONCLUSION: Superficial venous thrombosis is often considered to be benign although severe situations can occur in patients with a hemostatis disorder. Consideration of these different factors (risk factors, presence of a deep venous thrombus or pulmonary embolism) should be helpful in determining the etiology and for a better choice of a therapeutic option (medical/surgical) depending on the different subpopulations identified.     

Superficial vein thrombosis: risk factors,diagnosis, and treatment

Superficial vein thrombosis (SVT) risk factors are close to those of venous thromboembolism (VTE). Diagnosis is made in a clinical setting but ultrasonography is useful to eliminate concomitant deep vein thrombosis (DVT). For SVT of the lower limbs, which is the main location, varicose veins represent the principal cause but underlying conditions (e.g.: autoimmune diseases, malignancy or thrombophilia) must be sought in idiopathic, migrant or recurrent SVT and in the absence of varicose veins. Concomitant DVT and pulmonary embolism can occur in approximately 15% and 5% respectively. Historical treatments consist of anti-inflammatory agents plus elastic stockings and, in case of varicose veins, thrombectomy and stripping. Other treatments (anticoagulants, vein ligation) were assessed to limit the VTE risk. A one-month prophylactic dose of low molecular weight heparin plus elastic stockings could be the appropriate strategy in most cases. Other studies are needed before definitive conclusions can be drawn.     

Superficial vein thrombosis: risk factors, diagnosis, and treatment

Superficial vein thrombosis (SVT) is a very common disease even though its incidence has never been assessed properly. Until recently, the literature on this topic has been relatively poor, old, and with numerous methodologic drawbacks, probably because this disease was considered benign and trivial. However, the recent recognition of a frequent association with concomitant venous thromboembolism (VTE) (deep vein thrombosis [DVT] and pulmonary embolism [PE]) and the risk of subsequent VTE complications in patients with isolated SVT has revived interest and has encouraged new clinical research. SVT and VTE share many common predisposing risk factors. Even if varicose veins represent the main cause of SVT, several underlying conditions (e.g., malignancy, thrombophilia, autoimmune diseases) should be sought, especially in idiopathic, migrant, or recurrent SVT of nonvaricose vein patients. The diagnosis is made in a clinical setting but ultrasonography is useful to identify concomitant asymptomatic DVT. Many medical and surgical treatments have been suggested to relieve local symptoms and signs, prevent recurrences, and limit the VTE risk of SVT, but the evidence coming from the limited number of prospective randomized studies does not allow strong recommendations on the optimal treatment of SVT.     

下肢深静脉血栓形成的治疗现况

下肢深静脉血栓形成是常见的周围血管疾病,如果患者得不到及时、有效的治疗,将导致下肢淤肿、色素沉着,严重者可引起股青肿、肢体缺血坏死,患者丧失部分或全部劳动力。还有部分患者可随病情发展出现血栓脱落,引起肺栓塞,重者危及生命。目前下肢深静脉血栓形成的治疗分为非手术方法和手术方法,本文对近年治疗下肢深静脉血栓形成的方法进行综述。     

Incidence and risk factors for bilateral deep venous thrombosis of the lower limbs

The incidence of bilateral deep venous thrombosis in patients with single limb or bilateral symptoms was determined using duplex scan examination. In a prospective study, 157 inpatients with clinical suspicion of deep venous thrombosis underwent duplex scan evaluation of the lower extremities. Demographic characteristics, physical examination data, and risk factor information were collected. In all, 57 (36.3%) patients evaluated presented echographic evidence of acute deep venous thrombosis. Forty-six individuals presented unilateral thrombosis, and 11 patients presented bilateral disease (19.3% of all thrombosis, 7.0% of all patients). Sensitivity and specificity of clinical examination in identifying bilateral thrombosis was 27.2% and 93.3%, respectively. For the risk factors evaluated, active human immunodeficiency virus disease and iliofemoral thrombosis presented an increased risk for bilateral thrombosis (P = .045 and P = .049, respectively). The high incidence of bilateral deep venous thrombosis justifies bilateral duplex scan examination. Active human immunodeficiency virus disease and proximal thrombosis were risk factors for bilateral disease.     

Deep venous thrombosis: epidemiology,acquired risk factors

Deep vein thrombosis is a frequent disease with an annual incidence reaching 5 per thousand among subjects over 75 years. Major acquired risk factors for venous thrombosis include surgery, neoplasm, reduced mobility or paresis, and a previous episode of deep vein thrombosis. Among women, hormonal status (pregnancy, oral contraceptive, hormone replacement therapy) is responsible for the majority of all venous thrombotic events. The impact of other factors is controversial: obesity, tobacco use and varicose veins. Venous thrombosis is a multifactorial disease and analysis of the interactions between acquired and inherited risk factors is an extremely interesting field of investigation.     

急性下肢深静脉血栓形成腔内治疗的疗效分析

目的:探讨腔内治疗急性下肢深静脉血栓形成的疗效。方法:分析2009年1月年至2011年5月,采用导管溶栓和支架治疗16例急性下肢深静脉血栓形成的临床资料,采用静脉节段性病变评分和静脉临床程度评分评估手术疗效。结果:16例患者中,中央型静脉血栓14例,混合型下肢深静脉血栓形成2例。合并髂静脉压迫综合征11例。病史中位数为5 d(范围1～14 d)。患者均行静脉导管溶栓,其中12例接受髂静脉支架。随访中位数为6个月(范围1～24个月),术后30 d静脉通畅程度评分平均(1.38±0.90)分,低于术前〔(5.5±2.6)分;P=0.001〕,术前静脉临床程度评分平均(4.69±0.7)分,术后1个月、6个月静脉临床程度评分分别为(1.44±1.27)分、(1.42±0.9)分,低于术前(P=0.001,P<0.01)。术后1个月,6个月髂静脉支架通畅率均为83%。结论:选择性腔内治疗急性下肢深静脉血栓可显著改善患者临床症状,远期疗效有待进一步确定。     

静脉血栓形成的相关危险因素

静脉血栓是一种常见而危害极大的血管性疾病,其发生原因复杂。经典的Virchow理论认为：静脉壁损伤、静脉血流滞缓和血液高凝状态是引起静脉血栓的3个主要因素,该理论由19世纪德国著名病理学家Rudolf Virchow提出,现已被公认。     

D-dimer, oral anticoagulation, and venous thromboembolism recurrence

Venous thromboembolism (VTE) requires prolonged treatment to prevent late recurrences. However, the optimal duration of vitamin K antagonist (VKA) therapy is still controversial. More recently, D-dimer (D-d) has emerged as a predictive factor for recurrences. D-d has been evaluated both during and after VKA treatment. Some patients with DVT of the lower limbs have persistently high D-d during anticoagulation and this could reflect insufficient anticoagulation despite apparently adequate antithrombotic treatment. Altered D-d during anticoagulation is more frequent in patients with idiopathic or cancer-associated VTE than in those with secondary VTE. In subjects with an unprovoked VTE event, the time spent at near normal international normalization ratio (INR) values (< 1.5) during the first 3 months of treatment is associated with higher D-d during and after VKA treatment and with a higher risk for late recurrences. Moreover, the combination of altered D-d and inherited thrombophilia, and not residual venous obstruction, is associated with a significantly higher hazard ratio for recurrence. Preliminary results of a management study, the PROLONG study, indicate that subjects with normal D-d at 1 month after VKA withdrawal have a low risk of recurrence, and those with altered D-d have a significantly higher risk and deserve prolonged treatment.     

Epidemiology and risk factors for venous thrombosis

Venous thrombosis, including deep vein thrombosis (DVT) and pulmonary embolism (PE), occurs at an annual incidence of about 1 per 1,000 adults. Rates increase sharply after about age 45 years, and are slightly higher in men than women in older age. Major risk factors for thrombosis, other than age, include exogenous factors such as surgery, hospitalization, immobility, trauma, pregnancy, and the puerperium and hormone use, and endogenous factors such as cancer, obesity, and inherited and acquired disorders of hypercoagulation. This review focuses on epidemiology of venous thrombosis and the general implications of this in patient management.     

Frequency of malignant diseases in deep venous thrombosis of the lower extremities.

A retrospective investigation was carried out in a total of 200 patients (100 women, 100 men) with an average age of 61.0 years (19-97 years) with a phlebographically verified deep vein thrombosis of the lower limbs. It was examined whether and how frequently acute phlebothromboses are associated with a malignant underlying disease not detected up to that time. Specific diagnostics showed that a malignancy could be detected in 11.5% of all patients. As expected, the number of freshly discovered malignant diseases rose with increasing age. Seventy-one percent of all patients with a phlebothrombosis and a simultaneous tumor condition were more than 60 years old. The results clearly show that screening for occult malignant diseases should be carried out systematically and routinely in patients with etiologically unclear acute deep vein thromboses, at least from the 50th year of life onwards.     

老年人急性脑梗死合并下肢深静脉血栓形成30例临床分析

目的 总结老年人急性脑梗死合并下肢深静脉血栓(DVT)的治疗经验. 方法 对30例老年急性脑梗死合并DVT患者(脑梗死组)与31例单纯DVT老年患者(对照组)进行比较.治疗方法均为制动3 d;同时应用低分子肝素钙(商品名:博璞青)0.4 ml(100 IU/kg),皮下注射,12 h皮下注射1次,用药14 d.应用低分子肝素钙第10天加口服华法林,并根据国际标准化比率(INR)调整华法林的用量,为防止老年人发生出血,INR控制在2.0～2.5;并辅以输注低分子右旋糖酐500mg/d,14 d. 结果 所有患肢水肿明显减轻,治愈及无效均为0,两组均无肺梗死.但脑梗死组发生脑出血4例,此4例年龄均大于80岁,出血发牛时间在应用低分子肝素钙3～7 d,及时停用抗凝药,给予降颅压,3例痊愈,1例因颅内大出血合并肺部感染而死亡.对照组无死亡. 结论 对年龄大于80岁的急性脑梗死合并DVT患者应用低分子肝素抗凝治疗应谨慎.     

Inherited thrombophilic risk factors and venous thromboembolism: distinct role in peripheral deep venous thrombosis and pulmonary embolism

STUDY OBJECTIVES: To investigate whether the FII A(20210) mutation is associated with isolated pulmonary embolism (PE). DESIGN: Case-control study. SETTING: Five thrombosis centers in southern Italy. PATIENTS: Six hundred forty-seven consecutive referred patients with objectively documented venous thrombosis and 1,329 control subjects. Measurements and results: Medical histories were collected. The G-to-A transition at nucleotide 1691 within the factor V gene (FV Leiden) and the G-to-A transition at nucleotide position 20210 within the prothrombin gene locus (FII A(20210)), levels of anticoagulant factors, and levels of antiphospholipid antibodies were determined by standard techniques. Patients with deep venous thrombosis (DVT) of the lower extremities (n = 346) or with additional PEs (n = 175) showed similar prevalences of FV Leiden mutation (24.3% and 16.6%, respectively) and FII A(20210) mutation (14.2% and 12.6%, respectively), and similar deficiencies of natural anticoagulants (4.9% and 2.3%, respectively). In both groups, the frequencies of FV Leiden and/or FII A(20210) mutation were higher than those observed among 1,329 apparently healthy control subjects (4.8% and 4.4%, respectively; p < 0.0001). Among patients with isolated PE (n = 126), prevalences of FV Leiden (7.1%) and FII A(20210) mutation (8.7%) were similar to those of control subjects. Inherited thrombophilic abnormalities were less frequent among patients with PE only (15.6%) than among those with DVT only (37.0%; p < 0.001) or whose conditions were complicated by PE (28. 0%; p = 0.020). Adjusting for age and sex, FV Leiden mutation, FII A(20210) mutation, or both mutations were associated with DVT with PE (FV Leiden mutation: odds ratio [OR], 3.0; 95% confidence interval [CI], 1.6 to 5.5; FII A(20210) mutation: OR, 2.6; 95% CI, 1. 3 to 5.2; and both mutations: OR, 82.1; 95% CI, 7.5 to 901.2) or without PE (FV Leiden mutation: OR, 6.1; 95% CI, 4.0 to 9.3; FII A(20210) mutation: OR, 2.8; 95% CI, 1.7 to 4.8; and both mutations: OR, 167.5; 95% CI, 21.6 to 1,297.7), but not with isolated PE (FV Leiden mutation: OR, 1.2; 95% CI, 0.5 to 2.8; FII A(20210) mutation: OR, 1.2; 95% CI, 0.5 to 3.1; and both mutations: OR, 22.1; 95% CI, 1. 3 to 370.2). CONCLUSIONS: FII A(20210) mutation is associated with DVT in the lower extremities alone or when complicated by PE, but it is not associated with isolated PE.