Surgical treatment of acute deep venous thrombosis

In patients with venous thrombotic disease and in whom anticoagulation or thrombolytic therapy is inappropriate, ineffective, or even contraindicated, insertion of vena caval filters or venous thrombectomy must be considered.The primary indication for the placement of vena caval filters is in patients who have developed a pulmonary embolus and in whom anticoagulation is either contraindicated or in whom anticoagulation must be discontinued because of the development of bleeding complications. At the present time, either the Greenfield filter placed through a jugular, femoral, or axillary venotomy or the bird's nest filter are appropriate and appear to be the most effective and least fraught with complications.The use of venous thrombectomy has waxed and waned over the last several decades. At the present time, the procedure is advocated mainly for lower limb venous thrombosis which is extensive enough to threaten limb viability. On occasion, it may be appropriate to extend the indications for venous thrombectomy to include femoral thrombosis of less than 10 days duration or iliac thrombosis of less than 3 weeks duration with floating thombi at that level. Technical modifications which improve the patency of the obliterated veins which are predisposed to rethrombosis include the creation of a temporary arteriovenous fistula and meticulous care in removing the entire clot. The patient should be treated with anticoagulants postoperatively to prevent a recurrence of the problem.The main theoretical advantage of venous thrombectomy is a reduced incidence of postthrombotic syndrome. Objective data to support this contention do not exist.

---

Resumen En aquellos pacientes con trombosis venosas en quienes la anticoagulación o la terapia trombolítica aparecen inapropiadas, inefectivas, o aun contraindicadas, se hace necesario considerar la inserción de un filtro de vena cava o la trombectomía venosa.La indicación primaria para la inserción de filtros de vena cava reside en pacientes que han desarrollado una embolía pulmonar y en quienes la anticoagulación está contraindicada o debe ser descontinuada debido a complicaciones hemorrágicas. En la actualidad el filtro de Greenfield colocado por venotomía yugular, femoral, o axilar, o el filtro en nido de pájaro aparecen como los más apropiados y efectivos, y los que menos complicaciones inducen.El uso de la trombectomía venosa ha tenido sus altibajos en las últimas décadas. En el momento actual se propone el procedimiento principalmente para casos de trombosis venosas de las extremidades inferiores de tal gravedad que pongan en peligro la viabilidad del miembro afectado. En ocasiones pueden extenderse las indicaciones de la trombectomía venosa para incluir trombosis femorales o iliacas de menos de 3 semanas de duración y con trombos flotantes a estos niveles. Las modificaciones en la técnica quirúrgica orientadas a mejorar la permeabilidad de las venas obliteradas, que tienen predisposición a la trombosis, incluyen la creación de una fístula arteriovenosa temporal y el cuidado meticuloso en la remoción de la totalidad del coágulo. Los pacientes una vez operados deben ser tratados con anticoagulantes con el objeto de prevenir una recurrencia.La ventaja teórica principal de la trombectomá venosa es reducir la posibilidad de desarrollar el síndrome postflebítico. Sinembargo no existen datos objectivos para dar apoyo a esta propocición.

---

Résumé Chez les patients ayant une thrombose veineuse et chez qui le traitement anticoagulant ou thrombolytique est inefficace ou même contre-indiqué, on doit envisager la pose d'un filtre cave ou une thrombectomie veineuse chirurgicale.L'indication principale de la pose d'un filtre cave est l'embolie pulmonaire lorsque l'anticoagulothérapie est contre-indiquée ou doit être arrêtée en raison d'une complication hémorragique. A présent, on pose soit un filtre de Greenfield par voie jugulaire, fémorale ou axillaire, soit un filtre en nid d'oiseau, tous deux efficaces et donnant peu de complications.L'indication de la thrombectomie a varié pendant les dernières décades. A présent, on la préconise en cas de thrombose veineuse des membres inférieurs lorsque l'extension de celle-ci menace la vitalité du membre. Parfois il faut étendre l'indication de la thrombectomie veineuse à la veine fémorale ou iliaque. Celle-ci est indiquée lorsque la thrombose fémorale a moins de 10 jours, ou lorsque la thrombose iliaque a duré moins de 3 semaines avec caillot flottant à son niveau. Les modifications techniques qui améliorent la reperméabilisation des veines prédisposées à la rethrombose sont la création d'une fistule artérioveineuse temporaire et un soin méticuleux dans l'ablation de la thrombose. Une anticoagulation postopératoire est utile pour prévenir la récidive.L'avantage théorétique principale de la thrombectomie veineuse est une réduction de l'incidence du syndrome post-thrombotique. Ceci n'a pas encore été démontré objectivement.

     

Prevention and treatment of deep venous thrombosis

Postoperative venous thromboembolism (VTE) is a common cause of preventable patient morbidity and mortality. Hospitalized patients have multiple risk factors for VTE, which can exert a cumulative effect on the individual patient. Although effective thromboprophylactic measures are currently available, they are not commonly used for a number of reasons, in addition to heightened concern about increasing bleeding risk. Limited data are available characterizing the incidence of symptomatic VTE following major vascular surgery in the absence of thromboprophylactic therapy. Reported rates vary according to the type of surgery, type of prophylaxis used, and diagnostic modalities used for deep venous thrombosis (DVT) and pulmonary embolism (PE). Hospital-acquired DVT in the absence of thromboprophylaxis can occur in up to 40% of patients, occurring primarily in the proximal deep veins, which elevates the risk of PE. Risk factors for VTE in vascular surgery include limb ischemia, prolonged surgery duration, localized intraoperative trauma, and atherosclerosis. Advanced patient age is also a risk factor for VTE; however, the relationship between age and risk of VTE after surgery is complex and dependent on both the type of surgery and the underlying disease process. Evidence-based guidelines for venous thrombo-prophylaxis are now available; however, adoption of and compliance with these guidelines have lagged. Effective thrombo-prophylactic strategies exist and include both pharmacologic and nonpharmacologic approaches. For those surgical patients who develop a VTE, antithrombotic therapy remains the treatment of choice.     

Low molecular weight heparin versus oral anticoagulants in the long-term treatment of deep venous thrombosis

PURPOSE: The purpose of this study was to evaluate whether low molecular weight heparin (LMWH) could be equal or more effective than conventional oral anticoagulants (OAs) in the long-term treatment of deep venous thrombosis (DVT). METHODS: One hundred fifty-eight patients with symptomatic DVT of the lower limbs confirmed by means of duplex ultrasound scan were randomized to receive 3 to 6 months' treatment with nadroparine calcium or acenocoumarol. Quantitative and qualitative duplex scan scoring systems were used to study the evolution of thrombosis in both groups at 1, 3, 6, and 12 months. RESULTS: During the 12-month surveillance period, two (2.5%) of the 81 patients who received LMWH and seven (9%) of the 77 patients who received OAs had recurrence of venous thrombosis (not significant). In the LMWH group no cases of major bleeding were found, and four cases (5.2%) occurred in the OA group (not significant). The mortality rate was nine (11.1%) in the LMWH group and 7.8% in the OA group (not significant). The quantitative mean duplex scan score decreased in both groups during the follow-up and had statistical significance after long-term LMWH treatment on iliofemoral DVT (1, 3, 6, and 12 months), femoropopliteal DVT (1-3 months), and infrapopliteal DVT (first month). Duplex scan evaluation showed that the rate of venous recanalization significantly increased in the common femoral vein at 6 and at 12 months and during each point of follow-up in the superficial and popliteal veins in the LMWH group. Reflux was significantly less frequent in communicating veins after LMWH treatment (17.9% vs 32.2% in the OA group). The reflux rates in the superficial (22.4% in the LMWH group, 30.6% in OA group) and deep (13.4% vs 17.7%) venous system showed no significant differences between groups. CONCLUSIONS: The unmonitored subcutaneous administration of nadroparine in fixed daily doses was more effective than oral acenocoumarol with laboratory control adjustment in achieving recanalization of leg thrombi. With nadroparine, there was less late valvular communicating vein insufficiency, and it was at least as efficacious and safe as oral anticoagulants after long-term administration. These results suggest that LMWHs may therefore represent a real therapeutic advance in the long-term management of DVT.     

血管腔内治疗下肢深静脉血栓形成

目的 探讨下肢深静脉血栓的介入联合手术的血管腔内治疗方法.方法 76例下肢深静脉血栓形成的患者,在数字减影血管造影术(digtal subtraction angiography,DSA)监视下行下腔静脉滤器置入,采用手术取栓,辅以临时性股动静脉瘘,取栓后即刻造影观察有无血栓残留及髂静脉病变情况.残留血栓在DSA监视下用双腔取栓管取栓或大的鞘管吸栓.对髂静脉狭窄大于60%的患者予以血管成形术,其中62例置入髂静脉支架.结果 支架置入技术成功率100%,1例死于腰升静脉破裂出血.71例患者得到随访,其中髂静脉支架患者60例,随访3～30个月,平均随访21个月.65例下肢肿胀明显缓解,发现血栓复发6例(8.45%,6/71)其中支架内血栓形成4例(6.66%,4/60),支架移位6例(10.0%,6/60),支架断裂1例(1.66%,1/60).结论 在DSA监视下,取栓联合髂静脉支架置入可提高取栓后静脉通畅率,是治疗下肢深静脉血栓的重要方法.     

下肢深静脉血栓形成综合征的诊断及治疗

<正>急性下肢深静脉血栓形成(deep vein thrombosis,DVT)是常见的周围血管疾病,据国外文献报道每年有全世界200万人患下肢DVT[1]。DVT通常表现为患侧肢体突发肿胀、疼     

Surgical thrombectomy versus conservative treatment for deep venous thrombosis; functional comparison of long-term results

It is known that deep venous thrombosis (DVT) of the ilio-femoro-popliteal axis is frequently associated with irreversible damage to valvular competence of the veins and consequently with varying degrees of chronic venous insufficiency. Because preservation of the valvular function of deep veins can play an important role in preventing the postphlebitic syndrome we analysed and compared the long-term functional outcome of two equally large cohorts of patients treated either surgically for restoration of venous patency and valvular function (24 patients) or medically with heparin, oral anticoagulants and compression stockings (25 patients). The study was also intended to examine the impact of duration and extent of DVT as predictive factors of late outcome. Follow-up time was 7.6 and 7.9 years respectively, operative mortality nil. Assessment of venous function was based on clinical observations as well as on measurement of haemodynamic parameters. Non-fatal pulmonary embolism after onset of treatment occurred in both cohorts with an equal frequency of 13%. Patients operated on for ilio-femoral DVT were with few exceptions totally independent of any form of adjunctive hosiery which was in sharp contrast to the conservatively managed group. If onset of DVT had occurred more than 3 days earlier and extended from the ilio-femoral axis to the popliteo-crural level, surgery usually failed and patients were no better off than in the comparable medical group. The same pattern of late outcome was found for all other clinical and haemodynamic parameters; i.e. clinical signs of venous hypertension, valvular competence as judged by sonography, patient's self-assessment and the expelled volume and refilling time measured by dynamic plethysmography after standardised leg work. The mean expelled volume was 1.1 +/- 0.5 ml/100 g/min. for the surgical group treated early for ilio-femoral DVT and 0.7 +/- 0.5 ml/100 g/min for the corresponding medical group (P = 0.05). Recovery or refilling time was 50 +/- 21 s for the surgical group and 28 +/- 26 s for the medical group (P = 0.03). Thus, the clinical and haemodynamic effect of surgical thrombectomy was significantly superior to conservative management in ilio-femoral thrombosis treated within 3 days. For extensive thrombosis treated early the advantage of surgical thrombectomy was also evident, but the difference between the two treatment groups was not significant. The advantage of surgery was however totally lost in patients operated on for extensive DVT of long duration (i.e. greater than 3 days).(ABSTRACT TRUNCATED AT 400 WORDS)     

下肢深静脉血栓形成腔内治疗的评价

随着人们生活水平的提高，急性下肢深静脉血栓形成(deep venous thmmbosis，DVT)的发病率在逐年上升，目前已成为血管外科的常见病、多发病，而溶栓或取栓后血栓复发和血栓形成后综合征，将造成严重下肢功能障碍，是目前尚未很好解决的难题。近年随着以血栓消融、导管溶栓为主的各种腔内治疗技术的发展，使得更多的DVT病人得到安全、有效的微创治疗，但随着病例和经验的积累，     

下肢深静脉血栓形成诊治指南的解析

下肢深静脉血栓形成(deep vein thrombosis,DVT)是血管外科最常见的血管疾病,虽然下肢DVT的治疗在外科技术上远没有动脉性疾病的挑战性高,但总体下肢DVT的疗效还不是很理想,如深静脉血栓形成后综合征(post-thrombotic syndrome,PTS)的发生率仍较高。提高下肢DVT的疗效和患者的生活质量仍是血管外科医师不断努力的目标。随着对DVT研究的进一步加深,新技术和方法的应用,DVT的治疗有了较大的发展和进步,疗效有进一步的提高。但是除了常规的抗凝治疗外,有争议的问题依然很多。     

Current treatment of acute lower extremity deep venous thrombosis

The long-term complications of acute deep venous thrombosis (DVT) include recurrence, increased mortality, and the development of the postthrombotic syndrome. Rates of recurrent venous thromboembolism (VTE) are elevated in patients with cancer and thrombophilia. Heparin, administered either as unfractionated or low-molecular weight, is indicated for at least five days for acute DVT. Long-term treatment is currently a vitamin K antagonist with a variable duration depending on the etiology of the DVT and risk of bleeding. Novel anticoagulant agents that target factor Xa and directly inhibit thrombin are being studied in clinical trials and may one day replace vitamin K antagonists for the long-term treatment of VTE. Interventional approaches such as percutaneous mechanical thrombectomy have the potential to reduce clot burden in acute DVT with lower bleeding risks and help prevent development of the postthrombotic syndrome, a common and potentially debilitating complication of DVT.     

急性下肢深静脉血栓形成综合治疗的临床分析

<正>近年,急性下肢深静脉血栓形成(deep venous thrombosis,DVT)的发病率逐年升高,已成为血管外科的常见病。而其治疗是目前临床较棘手的问题,对其后遗症的治疗较困难。因此,DVT急性期的有效治疗显得尤为重要。     

Venographic comparison of subcutaneous low-molecular weight heparin with oral anticoagulant therapy in the long-term treatment of deep venous thrombosis.

PURPOSE: The primary objective of this study was to evaluate with venography the rate of thrombus regression after a fixed dose of low-molecular weight heparin (LMWH) per day for 3 months compared with oral anticoagulant therapy for deep venous thrombosis (DVT). Secondary endpoints were the comparisons of the efficacy and safety of both treatments. METHODS: This study was designed as an open randomized clinical study in a university hospital setting. Of the 165 patients finally enrolled in the study, 85 were assigned LMWH therapy and 80 were assigned oral anticoagulant therapy. In the group randomized to oral anticoagulant therapy, the patients first underwent treatment in the hospital with standard unfractionated heparin and then coumarin for 3 months. Doses were adjusted with laboratory monitoring to maintain the international normalized ratio between 2.0 and 3.0. Patients in the LMWH group were administered subcutaneous injections of fixed doses of 40 mg enoxaparin (4000 anti-Xa units) every 12 hours for 7 days, and after discharge from the hospital, they were administered 40 mg enoxaparin once daily at fixed doses for 3 months without a laboratory control assay. A quantitative venographic score (Marder score) was used to assess the extent of the venous thrombosis, with 0 points indicating no DVT and 40 points indicating total occlusion of all deep veins. The rate of thrombus reduction was defined as the difference in quantitative venographic scores after termination of LMWH or coumarin therapy as compared with the scores obtained on the initial venographic results. The efficacy was defined as the ability to prevent symptomatic extension or recurrence of venous thromboembolism (documented with venograms or serial lung scans). The safety was defined as the occurrence of hemorrhages. RESULTS: After 3 months of treatment, the mean Marder score was significantly decreased in both groups in comparison with the baseline score, although the effect of therapy was significantly better after LMWH therapy (49.4% reduction) than after coumarin therapy (24.5% reduction; P <.001). LMWH therapy and male gender were independently associated with an enhanced resolution of the thrombus. A lower frequency of symptomatic recurrent venous thromboembolism was also shown in patients who underwent treatment with LMWH therapy (9.5%) than with oral anticoagulant therapy (23.7%; P <.05), although this difference was entirely a result of recurrence of DVT. Bleeding complications were significantly fewer in the LMWH group than in the coumarin group (1. 1% vs 10%; P <.05). This difference was caused by minor hemorrhages. Coumarin therapy and cancer were independently associated with an enhanced risk of complications. Subcutaneous heparin therapy was well tolerated by all patients. CONCLUSION: The patients who were allocated to undergo enoxaparin therapy had a significantly greater improvement in their quantitative venographic score, a significantly lower recurrence rate of symptomatic venous thromboembolism, and a significantly lower incidence of bleeding than patients who underwent treatment with coumarin. LMWH can be used on an outpatient basis as a safer and more effective alternative to classical oral anticoagulant therapy for the secondary prophylaxis of selected patients with DVT.     

Late complications of asymptomatic deep venous thrombosis.

Forty-one patients who had all participated in studies about prophylaxis of postoperative deep venous thrombosis (DVT) were investigated 5-8 years after operation. Twenty-five had had asymptomatic DVT detected by 125I-fibrinogen uptake test or 99mTc plasmin scintigraphy and verified by phlebography, four of which were bilateral. They received anticoagulant treatment for three months. Sixteen patients had normal screening tests. At the follow up legs in which DVT had previously been diagnosed were compared with normal legs in patients who did not have DVT. There was no significant difference in subjective symptoms between the two groups of legs, although there were more complaints of oedema and restlessness in legs in which DVT had been diagnosed and varicose veins were more common. When the incidence of varicose veins before the operation and at the follow up was compared, more patients who had had a DVT had developed varicose veins. Blood volume and venous refilling time were measured by strain gauge plethysmography, and were significantly lower in those with a history of DVT than in normal legs. The results indicate impaired venous function in patients who previously had had asymptomatic DVT treated with anticoagulants.     

������֫���Ѫ˨�γɵ���������

目前对深静脉血栓形成 (DVT)如何治疗仍然有很大争议 ,多数以非手术治疗为主 ,其中以溶栓治疗更为普遍。我们经过多年的实践 ,认为手术治疗明显优于非手术治疗。首先要明确一个概念 ,手术治疗急性下肢DVT不是单靠手术取栓一种手段来完成 ,而是在手术的配合下 ,再加上溶栓、抗凝、祛聚及支持等综合治疗来完成。即先通过手术方法将下肢深静脉内的血栓尽量取净 ,再用溶栓药物溶解残留血栓 ,继而用抗凝及祛聚等药物 ,配合支持疗法等来预防血栓再形成。因此 ,手术取栓术应该理解为手术取栓加非手术的综合治疗。而且手术取栓后 ,可早期采用支持…     

髋部骨折患者术前静脉血栓栓塞症的预防与治疗

目的 分析髋部骨折患者深静脉血栓形成(DVT)的影响因素,探讨髋部骨折患者术前静脉血栓栓塞症的预防与治疗.方法 选取2008年6月至2010年6月间收治的531例髋部单发骨折患者,男242例,女289例;平均年龄59.2岁(28～93岁).股骨颈骨折336例,股骨转子间骨折183例,股骨转子下骨折12例.分析不同骨折类型、D-二聚体浓度、性别、年龄及术前制动时间与DVT发生率的关系.对于出现DVT的患者,给予放置下腔静脉滤器同时行骨折内固定术. 结果所有531例髋部骨折患者中,股骨颈骨折患者中21例发生DVT,股骨转子间骨折患者中34例发生DVT,股骨转子下骨折患者中无一例发生DVT.55例患者DVT均发生于术前,发生率为10.4%(55/531).髋部骨折患者年龄、性别对DVT的发生率无影响,差异无统计学意义(P值分别为0.347、0.376).D-二聚体浓度、骨折类型和术前制动时间对DVT的发生率有影响,差异有统计学意义(P值分别为0.002、0.017、0.037).55例发生DVT的患者均顺利完成手术. 结论对于髋部骨折患者,年龄、性别对DVT的发生不具有临床意义,D-二聚体浓度、骨折类型和术前制动时间对DVT的发生有临床意义.放置下腔静脉滤器可确保骨折内固定手术及术后康复安全顺利进行.     

Thrombolysis for deep venous thrombosis

The key questions addressed in this summary are whether clot removal should be part of the preferred therapy for patients with acute deep venous thrombosis (DVT), and whether there is evidence that a strategy of thrombus removal offers better outcomes for patients than anticoagulation alone. Evidence is defined as an outward sign or something that furnishes proof. Evidence in medicine is not limited to direct, blinded comparisons of one form of treatment compared with another but rather the body of knowledge that provides insight to clinicians to offer patient care. Evidence-based medicine follows from information available to form the foundation for the use of a treatment for a specific disease. Reports of strategies of thrombus removal for acute DVT, especially in patients with iliofemoral DVT, consistently demonstrate improved outcomes relative to postthrombotic morbidity. This summary reviews the evidence supporting this strategy as the preferred initial management of patients with extensive proximal DVT.     

The treatment of the expectant mother with deep venous thrombosis

Experience with 12 expectant mothers with DVT from 1978 to 1983 supports heparin therapy. After early experience with four patients with various doses of intravenous and subcutaneous mini-heparin both in and out of the hospital, we have selected a program of outpatient, self-administered adjusted subcutaneous heparin. There has been no maternal or fetal mortality. There have been no serious bleeding or post-phlebitic complications, although two patients have had flare-ups of superficial phlebitis during the follow-up over the last four-and-a-half years. There have been three subsequent pregnancies, two of which were first trimester miscarriages and one uneventful term delivery of a normal infant.