Outpatient treatment of acute deep venous thrombosis of the lower limbs

The outpatient management of acute deep vein thrombosis could replace the inpatient care for most patients. Fixed-dose, weight-adjusted low-molecular-weight heparins, as efficacious and safe as unfractionated heparin, allow home treatment for selected and eligible patients. The main exclusion criteria are severe renal insufficiency, high risk of bleeding, pulmonary embolism with unstable hemodynamics, allergy to heparin and suspected non-compliance. Programs for outpatient management need, after appropriate selection, adequate patient education, easy access to health-care professionals and daily follow-up during heparin treatment.     

Diameters of acute proximal and distal deep venous thrombosis of the lower limbs.

BACKGROUND: Duplex ultrasonography of the veins in the diagnosis of deep venous thrombosis (DVT) can be interpreted in a semi-quantitative mode by measuring the antero-posterior (AP) diameter of the thrombus. We report the values of the diameters of thrombi and the factors influencing these values. Therefore we propose a quantitative definition for DVT in duplex ultrasonography. METHODS: 1,017 patients (3,767 thrombosed venous segments), referred to the Emergency Angiology Unit from January 1994 to September 1996. Characteristics: 55% F, 45% M; mean age 68+/-18 years; 624 proximal DVT (61%) and 393 distal DVT (39%). Measurement by venous echography of the antero-posterior diameters of thrombi at 25 predetermined sites in the area of the vena cava. RESULTS: (In mm, median, 10th and 90th percentiles after regrouping of contiguous anatomical sites not statistically different): thrombus in the common iliac veins and the inferior vena cava (12 mm, 7-17); external iliac and common femoral veins (9 mm, 5-14); superficial femoral, deep femoral and popliteal veins (6 mm, 4-10); calf veins (5 mm, 4-8). The age of the patients, their sex, body mass index (BMI), whether they were in- or outpatients or the laterality of the thrombus never significantly influenced its diameter. CONCLUSIONS: It is very unusual to observe a diameter of under 5 mm in cases of DVT. For clinical research therefore, we propose 5 mm as the minimum threshold value for this diagnosis. This value could be used in the venous echographic definition of DVT, as a criterion for inclusion in a therapeutic trial, for example, or in an epidemiological study.     

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。     

Choice of an anesthetic technic for venous surgery of the lower limbs

The introduction of new anesthetic drugs and the option of administering anesthesia to outpatients for venous surgery of the lower limbs have modified the anesthesiologist's strategy. In addition, the final decision depends on the number of attending physicians (family doctor, phlebologist, surgeon, anesthesiologist, and of course, on the patient). The essential elements which determine the choice are: the methods preferred by the anesthesiologist, the patient's wishes, the duration, type and painful nature of the procedure. All types of anesthetic protocols may be employed. General anesthesia is often preferable because of its flexible administration and local anesthesia because it is simple to administer. Loco-regional anesthetics can be substituted for local types of anesthesia in bilateral surgical procedures but these are difficult to administer on an outpatient basis. Development of new drugs such as propofol is tending to give general anesthesia in outpatients an important role once again.     

Duration of oral anticoagulant therapy in deep venous thrombosis of the lower limbs

The optimal duration of oral anticoagulant therapy is a matter of debate. It is essential to balance the desired effect of the anticoagulants in reducing recurrences against the risk of major bleeding. Recent data suggest that it is necessary to tailor the duration of anticoagulation individually according to the topography of deep vein thrombosis (DVT) and the presence of risk factors. A six-week treatment for patients with isolated calf DVT is sufficient. For proximal DVT and/or pulmonary embolism, a short anticoagulant course seems sufficient in patients with temporary risk factors (three months) and a longer anticoagulant course (six months at least) is recommended for cases with permanent risk factors or idiopathic DVT. The inherited or acquired hypercoagulable states can be divides into those that are common and associated with a modest risk of recurrence (i.e. isolated factor V Leiden or G20210A prothrombin gene) and those are uncommon but associated with a high risk of recurrence (i.e. antithrombin, protein C or S deficiencies and anticardiolipin antibodies). Thus, the presence of one of these last abnormalities favours more prolonged anticoagulant therapy. For the high-risk of recurrence patients, there is a paucity of evidence based medicine particularly for patients with biological thrombophilia, and randomised controlled trials in this population are required. An assessment of low- or fixed-dose oral anticoagulation is also necessary in order to reduce the bleeding risk.     

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.     

Diagnosis of deep venous thrombosis of the lower limbs: performance of diagnostic tests

Deep-vein thrombosis is a frequent affection that needs precise diagnosis. Indeed, the clinical complications (from post-thrombotic syndrome to fatal pulmonary embolism) as well the risk of anticoagulant treatment require a precise diagnosis. Since clinical evaluation cannot assure reliably diagnosis by lack of sensitivity and specificity, complementary exams are needed. However, clinical assessment is an important part to decide further examinations. D-dimers assessment allows to role out the diagnosis of deep-vein thrombosis in a number of cases. Plethysmography and continuous Doppler are progressively given up. Compressive venous ultrasonography is now the exam of first choice. Scintigraphy, scanner and RMI must still be validated. Phlebography remains the gold standard in case of negative compressive venous ultrasonography and a high clinical probability.     

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。     

Pseudophlebitis of the lower limbs. A critical study from 102 suspected cases of deep venous thrombosis

Clinical diagnosis of deep venous thrombosis appears as uneasy, because of inconstant and non-specific symptoms. When studying a phlebitis, the risk to diagnose venous thrombosis is over 50 p. 100. This review of 102 patients, supposed to present with phlebitis, confirms such data. The diagnosis reliability depends mainly on the physician's experience. Examination and clinical research, combined with Doppler data make possible to perform a good diagnosis in 4 cases out of 5. However, in 20 p. 100, phlebography is strongly required, appearing as an essential examination. Analysis of epidemiologic and clinical data demonstrates the importance of certain data as for the diagnosis: female sex, age superior to 60 years, existence of two antecedents and/or a cardiopathy, a complex clinical picture might demonstrate a diagnosis of deep venous thrombosis. Post-phlebitic syndrome and skin infectious pathologies are the main pseudophlebitis etiologies. Popliteal cyst (often mentioned in English literature as a pseudophlebitis factor) is diagnosed in 11 p. 100 of cases.     

腘静脉置管溶栓术治疗非急性期深静脉血栓21例临床分析

目的 初步探讨腘静脉置管溶栓术治疗非急性期深静脉血栓的临床应用价值。方法 对21例亚急性和慢性深静脉血栓患者，在B超引导下行腘静脉置管溶栓术治疗。结果 所有患者均置管成功，其中3例未能通过髂静脉；出院前影像学检查示，完全再通4例，达到ⅡB型再通15例，其中5例接受髂静脉球囊扩张术，并继续置管溶栓，实现完全再通4例；其余2例为ⅡA型再通。结论 亚急性期甚至慢性期的血栓是可以溶解的，不能完全再通的病例，常存在血管狭窄或压迫，尤其是髂静脉，需结合球囊扩张血管成形术。     

Percutaneous transhepatic mechanical thrombectomy for acute mesenteric venous thrombosis.

PURPOSE: To present the management of symptomatic acute mesenteric venous thrombosis using a percutaneous thrombectomy device followed by resection of necrotic intestine. CASE REPORT: A 60-year-old woman developed acute abdomen and melena. Diffuse and extensive mesenteric and portal vein thromboses were diagnosed by computed tomography. Percutaneous transhepatic mechanical thrombectomy with an Oasis thrombectomy device removed approximately 80% of the thrombus in the portal and superior mesenteric veins. The patient underwent laparotomy immediately after thrombectomy, in which 100 cm of necrotic intestine was resected. Catheter-directed urokinase thrombolysis was performed for 3 days to address residual thrombi. The result was excellent, and the patient recovered without short bowel syndrome. CONCLUSIONS: The hydrodynamic thrombectomy system is a quick, reliable, efficient device that may offer an alternative to thrombolysis and surgical thrombectomy. Combining mechanical thrombectomy devices and surgery can be used to treat symptomatic acute mesenteric venous thrombosis.