Serial duplex ultrasound examinations for deep vein thrombosis in patients with suspected pulmonary embolism

Purpose: We have prospectively evaluated the need for serial venous duplex ultrasound examinations in an inpatient population with an initially normal study result.Methods: Patients were selected for study on the basis of clinical suspicion of pulmonary embolism and possible lower extremity deep vein thrombosis, a comorbid condition contributing to a nondiagnostic ventilation/perfusion lung scan, and an initially normal bilateral venous duplex ultrasound examination that included complete evaluation of the femoropopliteal system and the deep calf veins. Repeat duplex examinations were done during the same hospital admission between 5 and 14 days after the initial study.Results: Ninety-four patients with an initially normal duplex ultrasound examination result had repeat studies done at an average of 7.9 ± 2.6 days. Ninety-two examination results remained normal bilaterally. Two patients had isolated intramuscular calf vein deep vein thrombosis: one in the gastrocnemius system of both calves with associated calf tenderness at 11-day follow-up and one in a mid-calf soleal vein without associated symptoms at 10 days. No patients had any evidence of deep vein thrombosis in the femoropopliteal or tibioperoneal venous systems.Conclusions: Serial follow-up duplex ultrasound evaluation is unnecessary after an initially complete, normal study in patients with symptoms who have suspected pulmonary embolism and nondiagnostic ventilation-perfusion lung scans. (J Vasc Surg 1996;24:732-7.)     

妇科疾病患者发生症状性下肢深静脉血栓和症状性肺栓塞的临床对比分析

目的寻找妇科疾病患者从深静脉血栓进展为肺栓塞的高危因素,识别可能直接发生肺栓塞的高危患者并及时加以预防,在避免过度治疗的同时降低肺栓塞的发生。方法复习单纯深静脉血栓、单纯肺栓塞以及深静脉血栓合并肺栓塞的妇科患者的临床资料。结果从2000年1月1日至2012年10月31日,共有87 587名妇科疾病患者住院。其中0.43‰发生深静脉血栓(深静脉血栓组38例),0.18‰发生肺栓塞(肺栓塞组16例),0.21‰发生深静脉血栓合并肺栓塞(深静脉血栓合并肺栓塞组18例)。3组之间,血清纤维蛋白原水平具有显著性差异(P=0.007)。肺栓塞组和深静脉合并肺栓塞组中,67.7%的患者疾病原发于卵巢、输卵管或腹膜。在深静脉血栓组,65.8%的患者疾病原发于子宫、阴道和外阴(P=0.009)。双下肢深静脉血栓更易触发肺栓塞(P=0.015)。多元回归分析显示,疾病原发灶位于卵巢/输卵管/腹膜(P=0.004,OR=3.985),体重指数25.0kg/m2(P=0.018,OR=1.239),和双侧深静脉血栓(P=0.017,OR=6.81)的患者更容易发生肺栓塞。凝血酶时间值越低,越容易术前发生血栓(P=0.004,OR=2.416)。结论原发疾病位于卵巢/输卵管/腹膜、体重指数25.0kg/m2或者双侧深静脉血栓是深静脉血栓基础上发生肺栓塞,或者直接发生肺栓塞的危险因素。     

Role of venous duplex scanning in patients with suspected pulmonary embolism

Purpose: We examined the use of venous duplex scanning (VDS) in the diagnosis of pulmonary embolism (PE) at our institution.Methods: Patients undergoing lower extremity VDS from October 1988 through June 1995 were cross-referenced with those who underwent ventilation perfusion (V/Q) scans and pulmonary angiography (PA) for PE.Results: A total of 664 of 3534 VDS were for “rule out PE.” Deep venous thrombosis was found in 13%. A total of 256 VDS were in conjunction with V/Q scans in 249 patients, with only 8% undergoing PA. Deep venous thrombosis was present in 18% for those with both V/Q and VDS compared with 10% ( p < 0.01) for those with VDS as the sole study. The order in which V/Q, VDS, and PA were obtained and the relationship of positive studies was examined.Conclusion: We found no pattern to the sequence of tests ordered. V/Q scan rather than VDS should be the first study in the evaluation of PE. PE was diagnosed or excluded in nearly one third of patients based on V/Q as the initial study. A total of 29% of VDS could have been avoided. Treatment could be determined on the basis of VDS as the initial study in only 13%. We found only 14% incidence of positive PA in patients with nondiagnostic V/Q scans. We advocate judicious use of diagnostic tests in a stepwise fashion to appropriately treat patients with suspected PE. (J Vasc Surg 1996;24:768-73.)     

Asymptomatic pulmonary embolism in patients with deep vein thrombosis. Is it useful to take a lung scan to rule out this condition?

One hundred and sixteen patients with proximal deep venous thrombosis (DVT) confirmed venographically had perfusion and ventilation lung scans performed 48 hours after admission to assess the incidence of asymptomatic pulmonary embolism (PE). Sixty-six patients had normal lung scans, 29 had high-probability defects suggestive of PE, and 21 had indeterminate-probability of PE. Chest X-ray, electrocardiogram and arterial blood gases were of no value in assessing the lung scan results. Six out of 29 patients with a baseline lung scan of high probability of PE experienced acute signs and/or symptoms suggestive of pulmonary embolism while on heparin therapy. A repeated scan this time did not disclose new perfusion defects in any patients. In the absence of a baseline study, these scans may be interpreted as demonstrating pulmonary embolism on treatment and lead to unnecessary caval interruption procedures for failed heparin therapy.     

Management of symptomatic deep venous thrombosis and pulmonary embolism on a neurosurgical service

The authors present a retrospective analysis of the management of deep vein thrombosis (DVT) and pulmonary embolism (PE) in neurosurgical patients at the Massachusetts General Hospital from January, 1978, through June, 1982. There were 44 cases of DVT and 13 cases of PE. Management modalities included observation only, femoral vein ligation, inferior vena cava clipping, transvenous placement of an inferior vena cava filter or umbrella, and anticoagulation therapy. Six (75%) of eight patients with symptomatic DVT who were managed by observation alone had subsequent pulmonary emboli, and three (38%) died. Femoral vein ligation was followed by PE in one of four cases and led to significant leg swelling in two others. Neither observation alone nor femoral vein ligation can be recommended as routine management options. Partial inferior vena cava interruption with a De Weese clip, Kim-Ray Greenfield filter, or Mobin-Uddin umbrella all successfully prevented pulmonary emboli. The major problem associated with these methods was leg edema, which occurred in 47% of patients with clip placement, 25% with filter placement, and 21% with a Mobin-Uddin umbrella. Anticoagulation therapy was associated with a complication rate of 29% and a mortality rate of 15%. Fatal PE and paradoxical hypercoagulability with gangrene of a lower extremity were the causes of death. In one patient, hemorrhage into a glioblastoma occurred following discontinuation of anticoagulation therapy when the coagulation parameters were normal. The authors conclude that: 1) management with observation alone of patients with symptomatic DVT places the patient at risk for the development of life-threatening pulmonary emboli; 2) the safety and timing of therapeutic anticoagulation in postoperative neurosurgical patients or patients with tumors is unclear; and 3) partial interruption of the inferior vena cava with a transvenous filter successfully prevents PE and may represent a safer alternative to anticoagulation therapy.     

Predicting pulmonary embolism in postoperative patients with deep venous thrombosis of lower limbs

Ventilation-perfusion lung scans were done in 70 patients admitted because of an iliofemoral deep vain thrombosis (DVT), and diagnosed by venography. Eighteen items of clinical and laboratory information were measured to predict the presence of lung scan abnormalities consistent with asymptomatic pulmonary embolism. Eighteen patients had perfusion defects in the lung scan that were classified as «high probability of pulmonary embolism», while the lung scan was normal in 32 patients. Patients with an idiopathic DVT were at high risk of pulmonary embolism, but those with a postoperative DVT had a low embolic risk. In patients with a postoperative DVT two factors predicted pulmonary embolism: those patients who developed symptomatic DVT after an operation but had a normal lung scan showed higher platelet counts than their preoperative levels. Conversely, it they developed a pulmonary embolism their platelet count dropped from their preoperative levels.     

Infra-popliteal deep venous thrombi and the risk of symptomatic pulmonary embolism in hospitalized patients

Infra-popliteal veins include the tibial and peroneal veins, as well as the soleal and gastrocnemial veins collectively known as the calf muscle veins (CMVs). Acute infra-popliteal deep venous thrombi (DVTs) are often considered insignificant with regard to the risk of pulmonary embolism (PE). A retrospective review of 4035 consecutive lower extremity venous duplex scans were made in 3146 hospital patients at our Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL)-accredited vascular lab. Seven hundred sixteen (17.7%) duplex scans were positive for acute DVTs, and 112 (2.8%) were associated with PEs. The breakdown of positive duplexes for acute DVTs was as follows: 202 (28.2%) isolated femoral-popliteal DVTs with PE in 23 (11.4%), 304 (42.5%) isolated infra-popliteal DVTs with PE in 24 (7.9%) and 210 (29.3%) multilevel DVTs involving both vein segments (femoral-popliteal and infra-popliteal) with PE in 38 (18.1%). Of the 304 isolated acute infra-popliteal DVTs, 207 (68.1%) were isolated CMV DVTs with evidence of PE in 12 (5.8%). No statistically significant difference (P = 0.27) in the risk of PE between isolated femoral-popliteal and isolated infra-popliteal DVTs was noted. A significant number of patients (5.8%) with isolated CMV DVTs developed PE. Lower limb venous scans for DVTs should evaluate the infra-popliteal veins. Hospitalized patients with infra-popliteal DVTs should receive anticoagulation.     

Color-flow duplex scanning for the surveillance and diagnosis of acute deep venous thrombosis.

Compared with conventional duplex imaging, color-flow scanning facilitates the identification of veins (especially below the knee), decreases the need to assess Doppler flow patterns and venous compressibility, and allows veins to be surveyed longitudinally. These advantages translate into a less demanding and time-consuming examination. This study was designed to determine the accuracy of color-flow scanning for detecting acute deep venous thrombosis in patients in whom the diagnosis is clinically suspected and in asymptomatic patients at high risk for developing postoperative deep venous thrombosis. The diagnostic group included 77 limbs of 75 patients, and the surveillance group included 190 limbs of 99 patients undergoing total hip or knee replacement. All patients were prospectively examined with color-flow scanning and phlebography. In the diagnostic group, the incidence of thrombi in below-knee veins (47%) was approximately equal to that in above-knee veins (43%); but in the surveillance group, the incidence of thrombi in below-knee veins (41%) far exceeded that in veins above the-knee (3%). Nonocclusive clots and clots isolated to a single venous segment were more common in the surveillance group. In symptomatic patients, color-flow scanning was 100% sensitive and 98% specific above the knee and 94% sensitive and 75% specific below the knee. In the surveillance group, color-flow scanning was significantly (p less than 0.001) less sensitive (55%) for detecting thrombi, 93% of which were confined to the tibioperoneal veins. Negative predictive values were 100% and 88% for the diagnostic and surveillance limbs, respectively. Positive predictive values were 80% for the diagnostic limbs and 89% for the surveillance limbs. Color-flow scanning effectively excludes above-knee deep venous thrombosis in symptomatic patients and asymptomatic high-risk patients and predicts the presence of above-knee thrombi in patients in the diagnostic group with reasonable accuracy (97%). We conclude that color-flow scanning is as accurate as conventional duplex imaging and, because of its advantages, is the noninvasive method of choice for evaluating patients with suspected deep venous thrombosis. Its role in the surveillance of patients at high risk remains to be determined and awaits further clinical evaluation.     

急性肺动脉栓塞的双介入治疗

目的：探讨双介入技术在治疗下肢深静脉血栓致急性肺动脉栓塞中的价值。方法：25例下肢深静脉血栓致性肺动脉栓塞患，实施经皮穿刺下腔静脉滤过器置入术和经皮肺动脉置管溶栓治疗。结果：滤器和导管均成功安全置入，未发生相应并发症；经治疗临床症状明显改善，23例随访3－36月，无血管介入治疗的近远期并发症，无再发肺动脉栓塞，结论：下腔静脉滤器植入是预防下肢深静血栓致急性肺动脉栓塞的有效措施，双介入技术用于防治急性肺动脉栓塞是一种安全有效的方法。     

急性下肢深静脉血栓形成P-选择素与D-二聚体的变化及意义

目的 探讨下肢深静脉血栓形成(DVT)患者P-选择素与D-二聚体变化及其临床药物干预后的变化.方法 用流式细胞术(FCM),以单克隆抗体为探针测定40例下肢DVT患者及20例健康人P-选择素阳性表达率,应用免疫方法测定D-二聚体(D-dimer)含量.结果 DVT组在发病的早期P-选择素与D-二聚体阳性表达率均高于对照组(P均＜0.05),溶栓抗凝等治疗后不同时间P-选择素与D-二聚体阳性表达率呈降低趋势,其中应用奥扎格雷钠组与非奥扎格雷钠组比较P-选择素阳性表达率有显著差异.D-二聚体的变化无显著差异.出院1个月后P-选择素与D-二聚体含量明显降低,但P-选择素阳性表达率较正常人偏高.结论 急性DVT患者早期体内血小板活化,纤维蛋白溶解处于亢进状态;奥扎格雷钠能降低血小板活化;P-选择素,D-二聚体可做为DVT诊断的指标之一;出院后DVT患者仍是血栓形成的高危人群,需要定期随访.     

Nuclear medicine in the diagnosis of deep venous thrombosis and pulmonary embolism

Nuclear medicine techniques offer a variety of approaches to the diagnosis of deep venous thrombosis and pulmonary embolism. Several radionuclide methods are available to visualize venous structures, and many radiolabeled agents have been developed for direct visualization of blood clots, including platelets and monoclonal antibodies. Although still available on a limited basis, radiolabeled fibrinogen uptake studies have been replaced largely by newer methods. Ventilation-perfusion lung scanning remains the mainstay of nuclear medicine detection of pulmonary embolism as it has for the past two decades.     

Use of D-dimer to aid in excluding deep venous thrombosis in ambulatory patients

BACKGROUND: Duplex imaging is currently the gold standard for diagnosing deep venous thrombosis (DVT), but its nonselective use overburdens vasuclar laboratories, particularly during off hours. It is the purpose of this study to determine if a new D-dimer assay could be used as an aid in determing whether duplex imaging could be performed on an elective or emergent basis in patients with suspected DVT. METHODS: D-dimer levels were measured and venous duplex examinations were obtained in all patients. D-dimer assays were performed using the Tina-quant latex agglutination test (Roche Diagnostics, Mannheim, Germany). Venous duplex examinations were performed using colorflow doppler. RESULTS: Between September 1, 2002 and April 30, 2003, 148 patients were seen in the emergency department for suspected DVT. Nineteen patients (12.8%) had positive venous duplex examinations and 129 (87.2%) duplex examinations were negative. None of the 19 patients with positive venous duplex studies had D-dimer levels within of the normal range (0 to 0.49). The sensitivity, specificity, positive predictive value, and negative predictive value of the D-dimer test were 100%, 48.8%, 22.4%, and 100%, respectively. CONCLUSION: The D-dimer test can effectively used without adjuncting risk stratification as an aid in excluding the diagnosis of DVT in ambulatory patients. Its routine use could significantly reduce the need for the performance of emergent venous duplex examinations.     

Multi-institutional study of symptomatic deep venous thrombosis and pulmonary embolism in prostate cancer patients undergoing laparoscopic or robot-assisted laparoscopic radical prostatectomy

OBJECTIVES: The true incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing laparoscopic radical prostatectomy is unknown. Our aim was to determine the incidence of symptomatic DVT and PE and the risk factors for these complications. METHODS: Fourteen surgeons from 13 referral institutions from both Europe and the United States provided retrospective data for all 5951 patients treated with laparoscopic radical prostatectomy (LRP), with or without robotic assistance, since the start of their institution's experience. Symptomatic DVT and PE within 90 d of surgery were regarded as venous thromboembolism (VTE). DVT was diagnosed mostly by Doppler ultrasound or contrast venography and PE by lung ventilation/perfusion scan or chest computed tomography or both. Statistical analysis included evaluation of incidence of symptomatic DVT and PE and risk factors as determined by exact methods and logistic regression. RESULTS: Of 5951 patients in the study, 31 developed symptomatic VTE (0.5%; 95% confidence interval [CI], 0.4%, 0.7%). Among patients with an event, 22 (71%) had DVT only, 4 had PE without identified DVT, and 5 had both. Two patients died of PE. Prior DVT (odds ratio [OR]=13.5; 95%CI, 1.4, 61.3), current tobacco smoking (OR=2.8; 95%CI, 1.0, 7.3), larger prostate volume (OR=1.18; 95%CI, 1.09, 1.28), patient re-exploration (OR=20.6; 95%CI, 6.6, 54.0), longer operative time (OR=1.05; 95%CI, 1.02, 1.09), and longer hospital stay (OR=1.05; 95%CI, 1.01, 1.09) were associated with VTE in univariate analysis. Neoadjuvant therapy, body mass index, surgical experience, surgical approach, pathologic stage, perioperative transfusion, and heparin administration were not significant predictors. CONCLUSIONS: The incidence of symptomatic VTE after LRP is low. These data do not support the administration of prophylactic heparin to all patients undergoing LRP, especially those without risk factors for VTE.     

Use of the Greenfield filter in adolescents for deep vein thrombosis and pulmonary embolism

Serious venous thromboembolic disease is now recognized more frequently in the pediatric age group. Caval interruption is indicated most commonly for prophylaxis against life-threatening or recurrent pulmonary embolism (PE) when anticoagulation is ineffective or contraindicated. Greenfield vena caval filters have been utilized locally in 415 adult patients with 97% long-term patency and 5% recurrent embolization. Its application in adolescents is reported herein. Standard adult (30-mm) vena caval filters were placed in ten patients, ages 13 to 18. Four filters were required following PE, six were used for deep venous thrombosis (DVT) when anticoagulation was contraindicated, and one was inserted prophylactically. In eight patients, filter insertion was accomplished with local anesthesia, while two underwent filter placement under general anesthesia administered for other procedures. One filter was misplaced into the right renal vein, requiring a second filter insertion. All patients have been followed from 1 to 11 years with yearly vascular duplex imaging and radionuclide venograms documenting caval patency without clinical embolic sequelae. This duplicates the adult experience in safety and efficacy. As recognition of venous thromboembolism becomes more frequent in the pediatric age group, safe caval interruption may be necessary for those excluded from or not responsive to anticoagulation. This technique may be extended to smaller patients with miniaturization of both filter and carrier.