Cathéter à chambre implantable inextirpable : à propos de deux cas cliniques

We report two cases of encapsulated indwelling central venous catheter in adults. The patients involved were treated by chemotherapy and their catheter had been implanted for 15 and 6 years. However, this complication is well-known in children and a similar problem is frequently observed with pacemaker leads removal. The difficulty to remove the device is due to fibrous encapsulation of indwelling catheters in the vein wall. In all cases reported, the catheter was left in place. The potential main complications not yet observed are infection of the catheter and venous thrombosis.     

Thromboembolic complications after spinal surgery in trauma patients

Background?Deep venous thrombosis (DVT) and pulmonary embolism (PE) may be significant complications following spinal surgery. The incidence rate ranges from 0.5% to 2.5% in patients with symptomatic thromboembolic disease and up to 15% in patients with non-symptomatic thrombotic complications. We determined the incidence of symptomatic thromboembolism after spinal surgery in patients with postoperative systemic prophylaxis and investigated general and specific risk factors for development of this disease.

Patients and methods?We analyzed the clinical records of 978 patients who had undergone surgery of the spine because of trauma and who had been admitted to our level-I trauma center between 1980 and 2004. Spinal procedures included anterior and/or posterior spinal fusion, video-assisted thoracoscopic fusion, and spinal decompression. Symptomatic thromboembolic disease was diagnosed when patients showed significant clinical signs or symptoms of DVT or PE. In cases of DVT, diagnosis was confirmed by duplex scan of the lower limbs; in cases of PE, diagnosis was confirmed by CT-scanning of the thorax or at post mortem.

Results?The incidence rate of symptomatic thromboembolic complications was 2.2% (n 22). 17 patients showed clinical signs of deep venous thrombosis, with 4 of them developing pulmonary embolism subsequently. The other 5 patients developed pulmonary embolism without prior clinical signs of deep venous thrombosis. 6 patients died because of thromboembolic disease. Thromboembolic complications were more frequent in older patients and among males, as well as in patients with regular tobacco consumption and obesity. Thromboembolic complications were also seen more frequently in patients with surgical procedures at the lumbar spine, in patients with anterior spinal fusion, and in those with motor deficits in the lower extremities.

Interpretation?We found a rather low rate of clinically significant thromboembolic complications after spinal surgery because of trauma, compared to the results reported in the literature. Level of spinal surgery, surgical approach, and motor deficits in the lower extremities were identified as specific risk factors for DVT or PE. Age, sex, obesity and regular smoking were identified as general risk factors.     

Thromboembolic complications after spinal surgery in trauma patients

Background Deep venous thrombosis (DVT) and pulmonary embolism (PE) may be significant complications following spinal surgery. The incidence rate ranges from 0.5% to 2.5% in patients with symptomatic thromboembolic disease and up to 15% in patients with non-symptomatic thrombotic complications. We determined the incidence of symptomatic thromboembolism after spinal surgery in patients with postoperative systemic prophylaxis and investigated general and specific risk factors for development of this disease.

Patients and methods We analyzed the clinical records of 978 patients who had undergone surgery of the spine because of trauma and who had been admitted to our level-I trauma center between 1980 and 2004. Spinal procedures included anterior and/or posterior spinal fusion, video-assisted thoracoscopic fusion, and spinal decompression. Symptomatic thromboembolic disease was diagnosed when patients showed significant clinical signs or symptoms of DVT or PE. In cases of DVT, diagnosis was confirmed by duplex scan of the lower limbs; in cases of PE, diagnosis was confirmed by CT-scanning of the thorax or at post mortem.

Results The incidence rate of symptomatic thromboembolic complications was 2.2% (n 22). 17 patients showed clinical signs of deep venous thrombosis, with 4 of them developing pulmonary embolism subsequently. The other 5 patients developed pulmonary embolism without prior clinical signs of deep venous thrombosis. 6 patients died because of thromboembolic disease. Thromboembolic complications were more frequent in older patients and among males, as well as in patients with regular tobacco consumption and obesity. Thromboembolic complications were also seen more frequently in patients with surgical procedures at the lumbar spine, in patients with anterior spinal fusion, and in those with motor deficits in the lower extremities.

Interpretation We found a rather low rate of clinically significant thromboembolic complications after spinal surgery because of trauma, compared to the results reported in the literature. Level of spinal surgery, surgical approach, and motor deficits in the lower extremities were identified as specific risk factors for DVT or PE. Age, sex, obesity and regular smoking were identified as general risk factors.     

Value of a planned compression ultrasonography after an isolated superficial vein thrombosis: results from a prospective multicentre study

ObjectivesTo assess the efficiency of a systematically planned compression ultrasonography (SP-CUS) to detect venous thrombotic complications (VTCs) in patients with symptomatic isolated superficial vein thrombosis (SVT).DesignPost hoc analysis of a prospective, multicentre, cohort study (POST).PatientsAs many as 537 patients with CUS-confirmed isolated SVT undergoing an SP-CUS 8–15 days after the initial CUS.OutcomesAsymptomatic VTC (extension or recurrence of SVT, deep-vein thrombosis (DVT) of the lower limbs) diagnosed by the SP-CUS and symptomatic thromboembolic complications (VTC and pulmonary embolism (PE)) up to 3 months.ResultsVTC was suspected before or on the day of the SP-CUS in 18 patients (3.0%). Among the 519 asymptomatic patients (97%) undergoing SP-CUS, this revealed asymptomatic VTC in 12 patients (2.3%; 4 DVT, 4 SVT recurrences, 4 SVT extensions), none of whom subsequently experienced symptomatic thromboembolic events up to 3 months. Among the 507 patients with a normal SP-CUS, 29 (5.7%) presented symptomatic thromboembolic events during follow-up: 2 PE, 7 DVT, 9 SVT recurrences and 11 SVT extensions.ConclusionsIn this study, the SP-CUS detected a few asymptomatic VTC, but failed to identify patients at risk of thromboembolic events during follow-up. Use of an SP-CUS was therefore neither efficient nor cost effective.     

Chronic Thromboembolic Pulmonary Hypertension Due to Upper-Extremity Deep Vein Thrombosis Caused Thoracic Outlet Syndrome

We report on a 20-year-old woman diagnosed with pulmonary embolism (PE) and right subclavian vein thrombosis attributable to stasis caused by right clavicular prominence. At the 10-months follow-up, the patient had developed chronic thromboembolic pulmonary hypertension (CTEPH), and treatment was begun with a dual endothelin receptor antagonist. Very few cases of deep venous thrombosis of upper limb have been reported in relation to anatomical abnormalities. This case is also exceptional because the patient developed a chronic thromboembolic pulmonary hypertension, whose incidence is estimated at 0.5% of all symptomatic PE.     

Thromboembolism in plastic surgery: review of the literature and proposal of a prophylaxis algorithm

There is still less incidence of venous thromboembolic accidents in plastic surgery (% of unknown deep vein thrombosis and pulmonary embolism unknown) than in general surgery (6 to 12% of deep vein thrombosis and 0.3 to 1.1% of pulmonary embolism). However, these accidents present a dangerous and dreaded complication. Based on the recommendations of the Assistance Publique--H?pitaux de Paris and on a recently published medical study, an algorithm of preventive measures is proposed. The combination of the type of surgical procedure (liposuction, dermolipectomy and abdominoplasty) and the predisposing individual patient risk factors (age, obesity, varicose veins, estrogens, venous thromboembolism history, inherited disorders of coagulation) defines the level of thromboembolic risk which can be mild, moderate or high. Prevention is based on general guidelines (early mobilization, leg elevation, etc.); in addition, at every level of potential risk, the use of low molecular weight heparin (LMWH) and/or wearing anti-thrombosis stockings, as well as surveillance of detection of venous thromboembolism, notably the duplex venous scanning of lower limbs, will be adapted to each patient. This algorithm is a means to elaborate a rational, but unfixed strategy or protocol of prevention to reduce the risk of venous thromboembolic complications, and if they occur, to detect them at an early stage and to treat them in order to avoid evolution towards pulmonary embolism, notably mortal pulmonary embolism.     

A critical review of thromboembolic complications associated with central venous catheters

Purpose: Central venous catheters (CVC) are commonly used in critical care. While thrombosis is a well-recognized and frequent complication associated with their use, CVC-related thromboembolic complications, including pulmonary embolism (PE) and right heart thromboembolism (RHTE), occur less frequently and often evade diagnosis. Little information exists to guide clinicians in the diagnosis and management of CVC-related thromboembolic complications. SOURCE: We critically review and synthesize the literature highlighting the incidence of CVC-related thrombosis. We highlight the risk for developing thromboembolic complications and provide approaches to diagnosing and managing RHTE.Principle findings: The incidence of CVC-related thrombosis varies depending on patient, site, instrument, and infusate-related factors. Central venous catheters-related thrombosis represents an important source of morbidity and mortality for affected patients. Pulmonary embolism occurs in approximately 15% of patients with CVC-related upper extremity deep venous thrombosis (UEDVT). More frequent use of transesophageal echocardiography, in patients with suspected and confirmed PE, has resulted in increased detection of RHTE. While it is recognized that the occurrence of RHTE, in association with PE, increases mortality, the optimal strategy for their management has not been established in a clinical trial. CONCLUSION: Central venous catheter-related thrombosis occurs frequently and represents an important source of morbidity and mortality for affected patients. Our review supports that surgery and thrombolysis have both been demonstrated to enhance survival in patients with RHTE and PE. However, important patient, clot, and institutional considerations mandate that treatment for patients with RHTE and PE be individualized.     

Efficacité et tolérance du facteur VIIa recombinant dans l’hémorragie grave du post-partum : à propos d’un cas et revue de la littérature

We report the case of a severe postpartum hemorrhage (PPH) that was successfully treated with two administrations of recombinant activated factor VII (rFVIIa). Two major thromboembolic events (TEE) occurred shortly afterwards: the first was an acute lower limb ischemia at H3, the second was a cardiac arrest complicating a massive pulmonary embolism on day 5. Fortunately, both events had a favorable outcome. This case report allows us to discuss the role of rFVIIa during severe PPH and its potential responsibility in these two major TEE.     

Syndrome d’activation macrophagique et grossesse : à propos d’un cas

Haemophagocytic syndrome (HPS) results from an inappropriate stimulation of macrophages in bone marrow and lymphoid organs, leading to haemophagocytosis and hypercytokinemia. HPS may be primitive, essentially in pediatric population, or secondary to malignancy, infection or autoimmune disease. This disease is rare and prognosis is poor. A small number of cases during pregnancy have been described in literature. We report one HPS case in a pregnant patient at 21 week's gestation with systemic lupus erythematosus. We discuss diagnostic difficulties, obstetrical complications and therapeutic options.     

Critères d’arrêt de la grossesse en cas de prééclampsie

Few studies establishing clear criteria for the medical interruption of a pregnancy complicated by PE are available today. Most of these studies are either retrospective or observational. When combining an analysis of the available literature together with the experts’ opinions, one can propose the following set of criteria for therapeutic interruption of pregnancy in the setting of PE, which apply mainly for the severe forms of the disease. These criteria can be subdivided into maternal and fetal criteria.     

Successful renal transplantation in the right iliac fossa 2 years after serious deep venous thrombosis in a patient with systemic lupus erythematosus

Deep venous thrombosis (DVT) possibly occurs in the perioperative period, and induces serious complications such as a pulmonary embolism. On the other hand, allograft renal vein thrombosis leads to a high incidence of graft loss. We experienced a case in which a serious DVT occurred prior to renal transplantation; however, a successful renal transplantation in the right iliac fossa was performed after 2 years of anticoagulant therapy. It is suggested that the external iliac vein even after suffering from DVT can be anastomosed to an allograft vein successfully, when enough blood fl ow or a lower venous pressure is confirmed. However, one should be aware of the risk factors and the adequate management of thrombosis in renal transplantation because of the serious complications of DVT and the poor prognosis of allograft vein thrombosis.     

CDFI����֫���Ѫ˨�γ�����е�Ӧ��

目的　探讨二维彩色多普勒超声显像 (CDFI)对下肢深静脉血栓形成 (DVT)的诊断价值。方法　1998～ 2 0 0 3年对 97例下肢DVT病人进行CDFI检查 ,了解病肢深静脉的管壁、管径、血栓位置、大小、范围、静脉瓣功能及静脉血流情况。结果　 97例 (98条 )下肢DVT病例中 ,伴有下肢深静脉瓣功能不全者 6例。其中 ,中央型 2 1条 (2 1 4 2 % ) ,周围型 4 6条 (4 6 94 % ) ,全肢型 31条 (31 6 4 % )。病肢左右侧之比为 3 3:1(P <0 0 0 1)。结论　CDFI在下肢DVT方面具有特异性表现 ,可以成为下肢DVT诊断、预后判断和随访的首选方法。     

Deep venous thrombosis and pulmonary embolism after surgical treatment of ankle fractures: a case report and review of literature

Deep vein thrombosis and pulmonary embolism are major complications that can occur after ankle injuries. We present the case of a patient with an ankle fracture who developed deep vein thrombosis and massive pulmonary embolism after surgical treatment of the ankle fracture. A review of the published data on this topic is presented. The treating physician should assess patients with ankle fracture for their risk of developing a venous thromboembolic event on an individual basis and provide thromboprophylaxis for those with an increased risk of developing such complications.     

Pulmonary embolism following operative treatment of ankle fractures: a report of three cases and review of the literature

The risks of thromboembolism following operative treatment of ankle fractures are deep vein thrombosis (DVT) and pulmonary embolism (PE). These are potentially life-threatening complications. Many orthopedic surgeons fail to appreciate the potential complications of thromboembolic events because of their rare and delayed occurrence in foot and ankle operations. The purpose of this report is to describe the potential for DVT and PE following ankle operations. We present three cases in which patients who underwent operative treatment of ankle fractures subsequently developed PE. We also review the literature on the prevalence of thrombosis, risk factors, methods of prophylaxis, and use of prophylaxis in surgical procedures of the lower extremity.     

Imputabilité d’une mise en jeu du pronostic vital à un inhibiteur spécifique de la thrombine

We present the case of a 73-year-old man, operated on for paralyzing sciatica, who displayed acute postoperative respiratory distress and intra-alveolar haemorrhage following the administration of dabigatran etexilate, a new oral antithrombin used in the prevention of venous thromboembolism. This serious incident occurred in a patient who had a 20-year history of chronic thrombocytopenia (platelet level at 100 G/l) and a heparin-induced thrombocytopenia and in whom no other aetiology was found (tuberculosis, pneumorenal syndrome, etc.). The postoperative prevention of thromboembolic events in a patient with high risk bleeding requires intensive monitoring, notably, when prescribing new drugs such as new anticoagulant agents.     

下肢静脉曲张疾病腔内激光治疗并发症的防治

目的：探讨激光治疗下肢静脉曲张疾病的并发症原因及防治方法。方法：回顾性分析420例（525条肢体）下肢大隐静脉曲张患者的临床资料。其中单纯性大隐静脉曲张324例(422条肢体)，下肢深静脉瓣膜功能不全96例(103条肢体)。采用单纯激光治疗263条肢体，激光加小切口静脉团点状剥脱159条肢体，激光治疗联合股浅静脉戴戒术25条肢体和激光加小切口静脉团点状剥脱联合股浅静脉戴戒术78条肢体。 结果：有331条肢体（占63.1%）术后出现与激光治疗有关的并发症，其包括：皮下淤斑268条肢体（占51.1%）, 隐神经损伤198条（占37.7%），腿部皮下血栓性静脉炎33条（占6.3%），小腿轻度皮肤灼伤26条（占5.0%）。全组无切口感染发生，无术后深静脉血栓形成的病例。术后380例(90.5%)获随访3~40个月，单纯性大隐静脉曲张者术后有27条肢体复发（复发率6.4%），下肢深静脉瓣膜功能不全者术后有8条肢体复发（复发率7.8%）。结论：在应用激光治疗下肢静脉曲张疾病过程中应重视对其并发症的预防和治疗，以充分体现激光治疗安全和微创的特点。     

下腔静脉滤器在急性下肢深静脉血栓形成导管溶栓治疗中的必要性探讨

目的 探讨急性下肢深静脉血栓形成(deep venous thrombosis,DVT)患者行导管溶栓治疗(catheter direct thrombolysis,CDT)时,置入下腔静脉滤器的必要性.方法 回顾性总结2006年11月至2008年12月在仁济医院(东院)血管外科,经CDT及后续腔内治疗的急性下肢DVT患者临床资料.全组93例(93侧肢体),其中男35例,女58例;左下肢80例,右下肢13例;年龄28～88岁,平均60±29岁.病程5 h至15 d,平均(6.28±7.08)d.结果 93例患者中,置入滤器者30例,未置滤器者63例(67.7%,63/93).左下肢DVT未置滤器者占93.6%(59/63).溶栓后复查数字减影造影(digital subtraction angiography,DSA),77例髂-股静脉血栓完全溶解,其中70例于患肢髂静脉检出狭窄或闭塞性病变,57例接受了后续腔内治疗.全组未发生症状性肺栓塞(pulmonary embolism,PE).术后肺CTA检查:3例PE,均为置入下腔静脉滤器者;1例可疑PE,系未置入滤器者.结论 对于左下肢DVT且血栓未累及下腔静脉者,行CDT治疗时不必常规置入腔静脉滤器.     

Relationship between deep vein thrombosis and pulmonary embolism following THA and TKA

Patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) are at risk for venous thromboembolisms, including deep vein thrombosis and pulmonary embolism. Most deep vein thromboses are asymptomatic, but they can lead to long-term morbidity to the same extent as symptomatic events. The risk of complications of venous thromboembolisms depends on the location of thrombi; potential long-term complications include recurrent venous thromboembolism, postthrombotic syndrome, and chronic thromboembolic pulmonary hypertension. Risk of recurrence persists for several years after the initial event. Approximately 20% of recurrent events are pulmonary embolisms, and approximately half of those are fatal. The causal relationship between deep vein thrombosis and pulmonary embolism remains controversial. Some consider them distinct clinical entities, while others have found asymptomatic distal deep vein thrombosis to be associated with elevated risk of developing pulmonary embolism. Unique coagulation factors may be associated with orthopedic surgery patients that differentiate them from patients undergoing other types of surgery. Symptomatic and asymptomatic deep vein thrombosis can lead to the development of recurrent venous thromboembolism, pulmonary embolism, postthrombotic syndrome, and chronic thromboembolic pulmonary hypertension, all of which are associated with reduced quality of life and increased health care expenditures. Thromboprophylaxis is therefore important in patients undergoing THA or TKA. However, traditional anticoagulants are not ideal, particularly for long-term use. Orthopedic surgeons should be aware of the causes and potential sequelae of venous thromboembolism and of the new thromboprophylactic agents that can help prevent it.     

Incidence of thromboembolic complications in lumbar spinal surgery in 1,111 patients

Deep venous thrombosis (DVT) and pulmonary embolism (PE) cause significant morbidity and mortality in orthopaedic surgical practice, although the incidence following surgery to the lumbosacral spine is less than following lower limb surgery. Our objective was to compare our rate of thromboembolic complications with those published elsewhere and investigate whether the adoption of additional pharmacological measures reduced the incidence of clinically evident DVT and PE. This retrospective study was undertaken to investigate the incidence of DVT/PE during the 10 years from 1 January 1985 to 31 December 1994, and then to assess the effectiveness of an anticoagulant policy introduced during 1995 using low dose aspirin or LMH in high risk cases. All records for spinal operations were reviewed for thrombo-embolic complications by reference to the Scottish Morbidity Record form SMR1. To ensure that all patients were compliant with the policy, data for the whole of 1995 was omitted and the period 1 January 1996 to 31 December 2003 was taken to assess its effectiveness. Surgery was done with the patient in the kneeling, seated prone position which leaves the abdomen free and avoids venous kinking in the legs. Records of a total of 1,111 lumbar spine operations were performed from 1 January 1985 to 31 December 2004 were reviewed. The overall incidence of thrombo-embolic complications was 0.29%. A total of 697 operations were performed from 1 January 1985 to 31 December 1994 with two cases of DVT and no cases of PE giving thromboembolic complication rate of 0.29%. During the period 1 January 1996 to 31 December 2003, 414 operations resulted in one case of DVT and no cases of PE, a rate of 0.24%. The incidence of symptomatic thrombo-embolic complications in lumbar spinal surgery is low in the kneeling, seated prone operating position, whether or not anticoagulation is used.     

Thromboembolic complications in patients with advanced cancer: Anticoagulation versus greenfield filter placement

Thirty patients with Stage III/IV cancer and thromboembolic complications between 1987–89 were reviewed. Twelve patients had a deep venous thrombosis proximal to the calf diagnosed by duplex scanning or contrast venography, 15 patients had a pulmonary embolism diagnosed by a high-probability pulmonary ventilation/perfusion scan or arteriogram, and three patients had both deep vein thrombosis and pulmonary embolism. Patients were treated primarily with anticoagulation (Group A =20 patients) or a Greenfield filter (Group B=10 patients). Seventy-five percent (15/20) of the Group A patients developed 19 bleeding or thrombosis-related complications: major bleeding (7), recurrent deep venous thrombosis/pulmonary embolism (4), inability to attain consistent therapeutic anticoagulation levels (3), heparininduced thrombocytopenia (3), or progression of deep vein thrombosis (2). A Greenfield filter was eventually placed in 10 (50%) of the Group A patients without complications. Thirty percent (3/10) of the Group B patients developed progression of deep vein thrombosis that required anticoagulation. One other Group B patient died due to a guidewire-induced arrhythmia. Although patients with advanced cancers and venous thromboembolic disease have a high complication rate with either treatment, initial treatment with a Greenfield filter appears more definitive. Anticoagulation should be reserved for patients with progressive, symptomatic deep vein thromboses after placement of a filter.Presented at the Fifteenth Annual Meeting of the Peripheral Vascular Surgery Society, June 2, 1990, Los Angeles, California.Supported by a grant from the John F. Connelly Foundation.