Thrombolytic therapy for arterial thrombosis.

The major development in the field of intra-arterial thrombolytic therapy over the past year was the publication of the phase II results of the Thrombolysis or Peripheral Arterial Surgery study, which compared the safety and efficacy of catheter-directed thrombolysis and surgery as the initial treatment of acute arterial occlusion. The results are consistent with those of the prior two studies, showing little or no difference between surgery and thrombolysis in the most important endpoints of survival and amputation rate. Patients receiving thrombolysis needed fewer interventions, but this benefit was balanced by increased bleeding complications. Additional studies have, therefore, been aimed at identifying subsets of patients with acute arterial occlusion who are most likely to benefit from thrombolysis. These studies have refined the selection criteria for use of thrombolytic therapy over the past year. In addition, studies have been published evaluating new drug doses and regimens aimed at broadening the scope of thrombolytic therapy in patients with acute arterial occlusion.     

Thrombolytic therapy for prosthetic cardiac valve thrombosis

To determine the efficacy and safety of thrombolytic therapy for prosthetic valve thrombosis, a composite series of 41 patients who received either streptokinase or urokinase intravenously for this disorder were analyzed. The series comprised 3 patients treated at Rhode Island Hospital and 38 previously reported on. Short-term success was achieved in 32 patients (78%). Prosthetic valve thrombosis recurred in seven (22%) of the successfully treated patients, four of whom were retreated with thrombolytic therapy. A favorable clinical outcome was observed in each. Fever and venipuncture bleeding were the most frequent side effects. Systemic embolization occurred in 4 (15%) of 26 patients with either aortic or mitral prosthetic valve thrombosis. None of these latter patients experienced a permanent neurologic or circulatory deficit. It is concluded that thrombolytic therapy is of value in the treatment of prosthetic valve thrombosis.     

Distal deep vein thrombosis

Received from the Section of General Internal Medicine, University of Wisconsin Medical Center, 600 Highland Avenue, Madison, Wisconsin 53792.     

Thrombolytic therapy of antithrombin III-deficiency-induced mesenteric vein thrombosis in a newly operated patient

A 21-year-old patient presented with extensive thrombosis of the mesenteric veins. He was in a serious condition after laparatomy in another hospital. The cause of the thrombotic event was found to be an inherited antithrombin III-deficiency. As a sole therapeutic possibility a systemic lysis with streptokinase was performed and was followed by a favourable immediate result. Unfortunately the subsequent course was complicated by a histologically confirmed necrotizing arteritis which was responsible for the lethal outcome 57 days after admission.     

Upper extremity deep vein thrombosis

Upper extremities deep venous thrombosis (UEDVT) is a rare condition. According to the literature, approximately 4–10% of all cases of venous thrombosis may involve the subclavian, axillary or brachial veins. In the last few decades, the incidence of UEDVT has increased because of more frequent use of central venous catheters (CVCs) and cardiac pacemaker implantation. In addition, another common risk factor for UEDVT is cancer. UEDVT is classified as primary, approximately one-third of cases, which refers either to effort thrombosis or idiopathic UEDVT, or secondary, due to the presence of overt predisposing causes. The onset of UEDVT is usually characterized by arm swelling and pain, but may also be completely asymptomatic especially in patients with a long-term presence of a CVC. Ultrasonography represents a simple and accurate diagnostic tool to demonstrate the problem. UEDVT has major clinical consequences including pulmonary embolism, recurrences, post-thrombotic syndrome, and death. The role of thromboprophylaxis for those patients with a long-term CVC is still controversial. Unfractionated or low molecular weight heparin, followed by an oral anticoagulant are the most common treatments, with strategy of management similar to that of deep vein thrombosis of the leg. Thrombolysis/thrombectomy and surgical decompression are often successful, but less frequently used. Randomized controlled trials are warranted to clarify the optimal management of UEDVT, and to identify patients at the highest risk of recurrence who might benefit from long-term anticoagulation.     

血小板减少并深静脉血栓形成

1病历资料 患者女,60岁.因间断性血小板减少7年、腹胀腹痛2个月,于2006-08-15入中南大学湘雅二医院. 患者于1999年无明显诱因出现牙龈出血及双下肢出血点在当地住院,检查发现血小板减少(具体数值不详),给予口服泼尼松(剂量不详)治疗1月余,复查血小板恢复正常后出院.出院后多次复查血小板均正常,也未再出现出血倾向等.2005年因头晕、右侧肢体乏力1个月住入神经内科,诊断为"脑梗死","血小板减少性紫癜",血小板波动在(30～60)×109/L,经治疗后头晕、右侧肢体乏力好转,     

Upper extremity deep vein thrombosis

Upper extremity deep vein thrombosis (UEDVT) is associated with significant morbidity and mortality. The susceptible populations and risk factors for UEDVT are well-known. The presenting symptoms can be subtle, and therefore objective testing is necessary for diagnosis. The optimal diagnostic strategy has not been determined, and more than one test may be required to exclude the diagnosis. Proper treatment reduces the occurrence of complications, and treatment should include long-term anticoagulation if the patient has no contraindications. This article discusses the risk factors, pathogenesis, diagnosis, complications, and management of UEDVT.     

Therapy of deep vein thrombosis

Adequate anticoagulation treatment in patients with deep vein thrombosis reduces the risk of thrombus extension or embolization to less than 5%. Thrombolytic treatment may possibly prevent subsequent postthrombotic syndrome. Heparin is the initial treatment of choice for most patients with deep vein thrombosis. The dose is adjusted according to the results of tests such as the whole blood clotting time, thrombin clotting time, activated partial thromboplastin time or plasma heparin concentration. The most commonly used test is the activated partial thromboplastin time which should be maintained at 1 1/2 to two times the control level. Initially the test should be performed two to three times daily and when optimal adjustment has been established, clotting studies are required only at 24-hour intervals. In general, treatment with intravenous heparin should be continued for seven to ten days. Thereafter, for secondary prophylaxis, treatment with oral anticoagulants is carried out for six to eight weeks for symptomatic lower leg thrombosis, for twelve weeks in the case of proximal venous thrombosis and pulmonary embolism. Oral anticoagulant therapy with warfarin should be given overlapping the last few days of heparin with the dose adjusted to prolong the prothrombin time to 1.3 to 1.5 times control. Initially, the prothrombin time should be monitored weekly, thereafter at intervals of two to three weeks. If oral anticoagulant therapy is contraindicated, secondary prophylaxis with subcutaneous heparin given twice daily in doses sufficient to prolong the activated partial thromboplastin time to 1 1/2 times control is an effective and safe alternative. The major side effect of oral anticoagulant therapy, as well as that of heparin, is bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)     

Treatment of deep vein thrombosis

Most patients who present with deep vein thrombosis (DVT) can be treated with weight-adjusted, fixed-dose, low molecular heparin as an outpatient. The subsequent duration of oral anticoagulant therapy should be individualized according to the risk of recurrent venous thromboembolism and the risk of anticoagulant-induced bleeding. The risk of recurrence is low if thrombosis was provoked by a major reversible risk factor such as surgery; 3 months of treatment is usually adequate for such patients. The risk of recurrence is high if thrombosis was unprovoked ("idiopathic") or associated with a nonreversible risk factor such as active cancer; at least 6 months, and sometimes indefinite, anticoagulant therapy is indicated for such patients. The presence of an antiphospholipid antibody, and other selected thrombophilic states, favors more prolonged therapy within each of the categories noted previously. Systemic thrombolytic therapy helps to restore venous patency and probably reduces the risk of the postthrombotic syndrome; however, it is associated with an unacceptable risk of bleeding. Catheter-directed thromboylsis, particularly for isolated iliofemoral thrombosis, may be beneficial and needs further evaluation in controlled trials.     

Pregnancy and deep vein thrombosis

The diagnosis, treatment, and prevention of deep vein thrombosis (DVT) during pregnancy remain problematic. This article reviews the pathophysiology of pregnancy-related DVT and suggests diagnostic strategies, highlighting the pitfalls specific to this patient population. The treatment of DVT in pregnant patients is difficult because unfractionated heparin and low-molecular-weight heparins, the cornerstones of initial therapy, may have significant maternal side effects and warfarin can cause embryopathy and other adverse fetal effects. As well, there are limited data regarding the efficacy of anticoagulant therapy in the treatment and prophylaxis of DVT during pregnancy. This article briefly reviews the areas of controversy and provides recommendations for the treatment of acute DVT and thromboprophylaxis in pregnant patients.