Fatal pulmonary embolism despite an inferior vena cava filter in glioblastoma multiforme

Introduction: Patients with high-grade gliomas are at increased risk of pulmonary embolism and deep vein thrombosis. Treatment of this complication remains uncertain and options include anticoagulation or venous filters. Methods: We present a patient with a glioblastoma multiforme who developed a fatal pulmonary embolism in spite of an inferior vena cava filter. Conclusion: In spite of the theoretical risk of intratumoral hemorrhage, anticoagulation may be more effective and associated with fewer complications than inferior vena cava filters.     

Thrombosis of the inferior vena cava and malignant disease

Background

Inferior vena cava thrombosis (IVCT) is a rare event, and studies detailing its underlying aetiologies are scarce.

Methods

One hundred and forty-one IVCT patients (57% females, median age 47 years) were analysed with a focus on malignancy-related thrombosis and compared with 141 age- and sex-matched control patients with isolated lower-extremity deep vein thrombosis.

Results

Malignancies were more prevalent among IVCT patients compared with the control group (39% vs. 7.8%; P < 0.001). Malignancy-related IVCT more frequently involved the suprarenal and hepatic segments of the IVC and extended more often to the right atrium than IVCT did in non-cancer patients. Among IVCT patients with malignancies, renal cell carcinoma (38%) and other malignancies of the genitourinary tract (25%) were the most common tumours. Analysis of the underlying pathological mechanisms of malignancy-related thrombosis identified external compression of the IVC by tumour masses in 9 cases (16%), and progression of malignancy into the IVC (so-called “tumour thrombosis”) in 24 cases (44%). The remaining 22 cases (40%) were attributed to malignancy-related hypercoagulability and the presence of additional venous thromboembolism risk factors, such as previous surgery, immobilisation, or chemotherapy.

Conclusions

Malignancies substantially contribute to the risk of thrombosis involving the IVC. Tumour invasion, especially in cases of renal cell cancer and malignancy-related hypercoagulability are major triggering factors for thrombogenesis.     

膨体聚四氟乙烯人工血管表面肝素固化替代犬下腔静脉的表面抗凝血性能

背景：各种类型人工血管植入机体静脉后,由于血液与人工血管材料表面的不相容性和静脉内血流慢、压力低等原因,极易导致血管腔内血栓形成。目的：观察膨体聚四氟乙烯人工血管表面固化肝素后代替犬下腔静脉的表面抗凝血性能和长期通畅效果。方法：将壳聚糖分子中引入光敏基团后,通过光化学固定至膨体聚四氟乙烯材料表面,在酸性条件下将肝素以离子键形式接枝到壳聚糖上,在膨体聚四氟乙烯人工血管表面形成光滑的肝素层。以固化肝素的膨体聚四氟乙烯人工血管与未处理膨体聚四氟乙烯人工血管间置代替犬下腔静脉,检测其抗凝血性能。结果与结论：固化肝素的膨体聚四氟乙烯人工血管植入后2周、1个月人工血管内壁光滑,仅有少量附壁血栓形成,无充盈缺损,吻合口无狭窄,通畅率达100%;未处理膨体聚四氟乙烯人工血管植入后1周即显示人工血管内附有大量血栓成分,完全堵塞,形成丰富的侧枝。说明固化肝素膨体聚四氟乙烯人工血管是一种理想的下腔静脉替代物。     

Clinical course and predictive factors for complication of inferior vena cava filters

Rationale

The use of inferior vena cava (IVC) filters is associated with various complications. We aimed to elucidate the clinical course and predictive factors for complications of IVC filters, especially IVC penetration

Methods

A retrospective observational study was performed in 45 adult patients with retrievable IVC filters and follow-up computed tomography (CT) between January 2003 and December 2012. Primary outcomes were the prevalence and predictive factors of IVC penetration. Secondary outcome was other complications of IVC filters.

Results

IVC penetration following filter placement occurred in 87.6% of patients, and 57.8% of those involved significant penetration. Embedding of filter tips, suggestive of lateral tilting, was observed in 51.1%. Both Vertebral body erosions and aortic penetrations were seen in 4.4%, but they were asymptomatic. Longer indwelling duration of the IVC filter was significantly associated with a higher grade of IVC penetration, and the risk of significant IVC penetration increased in patients with the filter indwelling time of more than 20 days and an IVC diameter of less than 24.2 mm.

Conclusions

In patients with a retrievable IVC filter, IVC penetration on CT was common, and significant IVC penetration was associated with a longer indwelling time of the IVC filter and a lesser IVC diameter.     

下腔静脉加压法与Valsalva动作在提高卵圆孔未闭检出率中的对比研究

目的 探讨下腔静脉加压法与Valsalva动作在经食道超声心动图(Transesophageal echocardiography,TEE)对卵圆孔未闭(Patent foramen ovale,PFO)检出率中的差异。方法 回顾性分析手术证实的PFO患者114例,包括对比增强经颅多普勒超声(Contrast-enhanced transcranial Doppler ultrasonography,c-TCD)少量右向左分流(Right-to-left shunt,RLS)(n=51)组、中量RLS(n=37)组、大量RLS(n=26)组,记录常规TEE超声、Valsalva动作配合下TEE检查、PFO封堵术前无痛TEE下下腔静脉加压检测,分析3组房间隔右向左一过性分流信号发生率的不同和其它临床因素在3组间的差异。结果 3组身体质量指数(Body mass index,BMI)、高血压病、高脂血症及冠心病的比例无明显差异(P>0.05); 大量RLS组患者年龄明显小于少量RLS及中量RLS组(P<0.05)。少量RLS及中量RLS组患者Valsalva动作和下腔静脉加压后较常规TEE下PFO的显示率均有提高(P<0.01); 大量RLS组患者Valsalva动作和下腔静脉加压后PFO显示率改变不明显(P>0.05)。结论 大量RLS患者较少量及中量RLS患者的年龄小,更容易早期出现临床症状; 下腔静脉加压法可以替代Valsalva动作提高TEE超声对PFO的检出率。     

Predictors of attempted inferior vena cava filters retrieval in a tertiary care centre

Background

Retrieval rates of optional recovery inferior vena cava (IVC) filters in US hospitals range from 11 - 70%. We conducted a retrospective study in a Canadian tertiary care centre to determine retrieval rates and predictors of filter removal.

Methods

Consecutive patients who had a retrievable IVC filter inserted or removed between January 2007 and December 2010 were identified. Data collected included baseline demographics, indications for filter insertion and removal, documentation of an IVC filter management plan, reasons for non-retrieval, complications, and death.

Results

275 patients with a median age of 60 years were followed in hospital for a median of 17 patient-days (range 1–876). Indications for filter placement were acute or prior VTE with contraindication to anticoagulation (72.4%), high risk of PE (11.3%) and primary prophylaxis (13.8%). Retrieval was attempted in 165 patients (60%) and was successful in 146 patients (53.1%). The most common reason for failed retrieval was filter thrombus. Predictors of attempted retrieval included documentation of filter plan (odds ratio [OR] 16.7; p < 0.001), surgical indication for IVC filter insertion (OR 4.8; p = 0.002), age ≤ 70 years (OR 3.8; p = 0.001), Hematology service involvement (OR 3.0; p = 0.006), and presence of metastatic cancer (OR 0.2; p = 0.001). Thrombotic complications occurred in 48 patients, including 3 patients who died of fatal PE.

Conclusion

Our filter retrieval rate is suboptimal. Improvements in follow-up documentation or a dedicated clinical service may help increase retrieval rates.     

卒中后深静脉血栓形成调查及危险因素探讨

目的 调查卒中后急性期和随访期深静脉血栓形成(DVT)发生率,并探讨DVT发生的危险因素.方法 采用多中心、前瞻性研究设计.所有患者于发病后10～14 d进行双下肢静脉超声检查,出院后继续随访6个月.计算出卒中后急性期和随访期DVT发生率.通过比较卒中后并发DVT与卒中后无DVT的患者多种相关因素,筛选出卒中后DVT发生的危险因素.结果 卒中急性期DVT发生率为4.49%,其中有DVT症状者为51.6%,无症状者为48.4%;多因素Logistic分析显示:年龄(≥70岁,OR=1.63,95%CI 1.08～2.84)、卧床(OR=4.85,95%CI 2.65～9.68)、Wells评分≥2(OR=3.96,95%CI 1.86～7.86)、下肢NIHSS评分≥3分(OR=4.56,95%CI 2.07～8.85)、D-二聚体水平高(OR=3.45,95%CI 2.01～8.52)、Barthel指数(BI)评分低(OR=2.98,95%CI 1.52～6.47)、是否康复治疗(OR=1.82,95%CI 1.22～3.43)、是否抗凝治疗(OR=1.91,95%CI 1.34～4.92)是急性期卒中患者DVT发生的独立危险因素,其中康复治疗和抗凝治疗是保护因素;卒中随访期DVT发生率为1.51%,年龄(≥70岁,OR=1.82,95%CI 1.21～3.98)、出院后仍卧床(OR=5.12,95% CI 2.82～11.32)、出院时下肢NIHSS评分≥3分(OR=4.25,95%CI 2.11～7.87)、出院时BI评分低(OR=2.18,95%CI 1.18～6.23)、急性期有DVT(OR=3.81,95% CI 1.87～7.48)是随访期卒中患者DVT发生的独立危险因素.结论 卒中后DVT多发生于老年患者,48.4%DVT无症状,卒中患者发生DVT的独立危险因素多,对有上述危险因素卒中患者进行DVT监测和预防干预十分必要,康复治疗和抗凝治疗可能能降低DVT的发生.     

Inferior vena cava thrombosis and its relationship with the JAK2V617F mutation and chronic myeloproliferative disease

Background

Splanchnic vein thrombosis (SVT) is a typical manifestation of polycythaemia vera (PV) or essential thrombocythaemia (ET). The recently discovered JAK2V617F somatic mutation is closely associated with chronic myeloproliferative disease (CMD). We investigated whether thrombosis involving the inferior vena cava (IVC) is also related to the JAK2V617F mutation or CMD.

Methods

Blood samples were obtained from 40 IVC thrombosis patients. Fifty-three patients with isolated lower extremity deep vein thrombosis (LE-DVT) and 20 SVT patients served as controls. The presence of the JAK2V617F mutation was assessed by real-time polymerase chain reaction (RT-PCR).

Results

The JAK2V617F allele was not detected in any of the IVC thrombosis patients but was detected in one patient (2%) with isolated LE-DVT. However, the mutation-carrying patient did not exhibit symptoms of CMD. Even after an observation period of 30 months, the patient's complete blood cell count did not exhibit any pathology. In contrast, the JAK2V617F allele was detected in four patients with SVT (20%) and CMD.

Conclusion

According to our data, there is no evidence that IVC thrombosis is associated with the JAK2V617F mutation or the presence of chronic myeloproliferative disease.     

Protein Z levels and anti-protein Z antibodies in patients with arterial and venous thrombosis

INTRODUCTION: The thrombotic risk associated with protein Z (PZ) deficiency is unclear. Anti-protein Z (anti-PZ) has been described as a risk factor in unexplained embryo demise. The aim of our study was to evaluate a possible PZ deficiency and presence of anti-PZ antibodies on thrombotic diseases. MATERIAL AND METHODS: We performed a case-control study on 114 patients with preexisting arterial or venous thrombosis (50 and 64, respectively). Thrombosis was studied based on etiology (creating factor risk subgroups) and on specific thrombotic disease. RESULTS: PZ levels of patients were significantly lower compared to controls (1709+-761.3 ng/mL vs. 2437+-964.7 ng/mL P=0.001). The high arterial risk factor subgroup showed the lowest PZ level (1267.5+-609 ng/mL) whereas the rest of arterial and venous etiological subgroups presented similar PZ levels. Patients with peripheral artery disease had the lowest PZ level (1022+-966 ng/mL). The rest of arterial and venous thrombotic diseases presented similar PZ levels. A significant increased risk for arterial and venous thrombosis for the lowest (<1685 ng/mL) quartile of PZ has been founded (OR:52, P=0.001 and OR:18, P=0.007, respectively). Anti-PZ antibodies were negative in the majority of patients, although mean anti-PZ IgG antibody levels in the arterial thrombosis group were significantly higher compared to venous thrombosis and control groups (P=0.05 and P=0.005, respectively). CONCLUSIONS: The results suggest that both arterial and venous thrombotic events are related to low PZ levels and that low PZ concentrations are associated with thrombosis in our study. In arterial thrombosis our findings strengthen previous studies that related low PZ levels to atherosclerotic disease. Anti-PZ antibodies do not seem to play a potent role in thrombosis.     

Role of prophylactic filter placement in the endovascular treatment of symptomatic thrombosis in the central veins

Objectives

To evaluate the role of filter implantation in reducing the incidence of fatal pulmonary embolism during the endovascular treatment of thrombosis in the major tributary of the superior vena cava (SVC).

Methods

From October 2004 to October 2008, we conducted a cohort study of 40 patients with thrombosis of the central veins who were preparing for endovascular interventions and received or did not receive filter. The symptom scores were measured, the incidence of pulmonary embolism (PE) was observed, and patient follow-up studies were conducted for three years.

Results

One week after therapy, the symptom score improved in both groups compared with before therapy (P < 0.001), but no significant difference was found between the scores of the two groups (P > 0.05). Four patients in the control group died from PEs after therapy, but no patients in the filter group presented evidence of PE. The survival rates at 1, 2, and 3 years (72.9%, 50%, and 27.1%, respectively) for the filter group were higher than those for the control group (47.6%, 19.0% and 14.3%, respectively; P = 0.015). The survival time of patients in the filter group with bronchogenic carcinoma (18 ± 2 months) was longer than that of the patients in the control group (12 ± 2 months) after the endovascular treatment (P < 0.001).

Conclusions

Prophylactic filter placement could be a safe and effective method for preventing PE in pre- or post-endovascular-treated patients with thrombi in their central veins.     

静脉窦血栓患者血管内皮生长因子水平与预后的关系

目的 探讨血管内皮生长因子(vascular endothelial growth factor,VEGF)在静脉窦血栓患者中的表达水平及其与近期预后的关系.方法 采用ELISA法检测静脉窦血栓患者(84例)和健康对照人群(70例)血浆VEGF水平,随访12个月评估静脉窦血栓患者不良终点事件发生情况.结果 静脉窦血栓患者血浆VEGF水平较正常对照组明显升高[(195.15±24.62)μg/mL vs.(165.66±20.60)μg/mL(P＜0.01)].随访结束后,高VEGF组(31例,VEGF≥200 μg/mL)发生不良事件12例,低VEGF组(53例,VEGF＜200 μg/mL)发生不良事件11例,Kaplan-Meier生存曲线显示2组差异有统计学意义(P=0.03).另外,不良终点事件发生者(23例)血浆VEGF水平较无不良终点事件发生者(51例)明显增高(P＜0.01).结论 静脉窦血栓形成可诱导VEGF表达增强,VEGF水平升高越明显近期预后越差,可能与血管源性脑水肿有关.     

Acquired hydrocephalus associated with superior vena cava syndrome in infants

We report observations on children with the unusual combination of superior vena cava syndrome in infancy followed by communicating hydrocephalus. Following retrospective review of hospital discharges at a tertiary children's hospital, three children were identified in a 13-year period. Two term infants were treated with extracorporeal membrane oxygenation for pulmonary failure associated with congenital diaphragmatic hernia. These infants had septic complications of central venous lines. A post-term infant required reconstruction of the superior vena cava following cannulation for cardiac bypass surgery to repair transposition of the great vessels. Thrombosis occurred and was followed by the sequential development of superior vena cava syndrome and communicating hydrocephalus. The findings in these patients suggest that communicating hydrocephalus may be caused by superior vena cava syndrome. This is an unusual complication of therapeutic manipulation of the heart and great veins. Cerebrospinal fluid shunting may be required. Received: 6 May 1996     

出血性卒中患者下肢深静脉血栓形成风险预测模型的构建与验证

目的构建下肢深静脉血栓形成(DVT)的风险预测模型,以评估和预防出血性卒中患者的下肢DVT。方法采用便利抽样法收集2018年7月至2020年7月天津医科大学总医院神经外科重症监护病房收治的547例出血性卒中患者的临床资料。547例患者分为建模组(447例)和外部验证组(100例),采用彩色多普勒超声确诊下肢DVT。采用单因素和多因素logistic回归分析法判断发生下肢DVT的危险因素,并构建下肢DVT风险预测模型;绘制受试者工作特征曲线并计算曲线下面积(AUC)以及采用Hosmer-Lemeshow拟合优度检验评价风险预测模型的效能;应用外部验证法检验模型的灵敏度、特异度和一致性。结果建模组纳入的447例患者中,共112例(25.1%)确诊为下肢DVT。单因素分析结果显示,年龄、格拉斯哥昏迷评分、全身麻醉手术、镇静镇痛药物、降温毯物理降温、糖尿病史、高血压病史、下肢肌力分级及血浆D-二聚体水平是出血性卒中患者发生下肢DVT的影响因素(均P<0.05)。进一步行多因素logistic回归分析结果显示,年龄(OR=1.063,95%CI:1.036~1.092,P<0.001)、镇静镇痛药物(OR=5.115,95%CI:2.620~9.986,P<0.001)、降温毯物理降温(OR=34.991,95%CI:14.009~87.396,P<0.001)、高血压病史(OR=2.671,95%CI:1.275~5.594,P=0.009)、血浆D-二聚体水平(OR=7.026,95%CI:3.324~14.851,P<0.001)是出血性卒中患者发生下肢DVT的危险因素。风险预测模型的检验结果显示,P=0.648,AUC=0.912,约登指数最大值为0.714,对应的灵敏度为91.4%,特异度为80.0%,截断值为0.226。外部验证组100例患者的数据分析结果显示,该模型的灵敏度为91.4%,特异度为80.0%,一致性指数为0.84。结论基于临床参数所构建的下肢DVT风险预测模型简单、便捷,具有较高的特异性,可为出血性卒中患者下肢DVT风险的预防、评估及诊疗提供参考。     

Serum Lipoprotein (a) Levels in Patients with First Unprovoked Venous Thromboembolism is not Associated with Subsequent Risk of Recurrent VTE

Introduction

Case-control studies suggest that elevated lipoprotein (a) (Lp(a)) is a risk factor for first venous thromboembolism (VTE). Lp(a) has not been prospectively investigated as a possible risk factor for recurrent VTE in first unprovoked VTE patients. We sought to determine if serum Lp(a) levels in patients with unprovoked VTE who discontinue anticoagulants after 5 to 7 months of therapy predict VTE recurrence in a prospective cohort study.

Materials and Methods

Serum Lp(a) measurements were obtained from 510 first unprovoked VTE patients treated for 5 -7 months with anticoagulants in a 12 center study. Patients were subsequently followed for a mean of 16.9 months (SD ± 11.2) for symptomatic VTE recurrence which was independently adjudicated with reference to baseline imaging.

Results

There was no significant association between Lp(a) as a continuous variable and recurrent VTE nor in gender stratified subgroups. No statistically significant differences were observed in the median Lp(a) concentrations between patients who recurred and those who did not recur (median (interquartile range): 0.09 g/L (0.17) versus 0.06 g/L (0.11) respectively; p = 0.15). The Lp(a) cut-off point of 0.3 g/L was not significantly associated with recurrent VTE for the overall population nor in gender stratified subgroups.

Conclusions

Elevated serum Lp(a) does not appear to be associated with recurrent VTE in patients with history of first unprovoked VTE and may not play a role in identifying patients with unprovoked VTE at high risk of recurrence. There was no optimal predictive threshold for the overall population or for sex sub-groups and Lp(a) ≥ 0.3 g/L was not a significant predictor of recurrent VTE.     

神经重症患者静脉血栓栓塞的发生率、危险因素及住院结局分析

目的 探讨神经重症患者静脉血栓栓塞(venous thromboembolism,VTE)的发生率,并分析VTE相关的危险因素及其对住院结局的影响.方法 基于电子病历系统数据回顾性分析2019年10月-2020年9月首都医科大学附属北京天坛医院的神经重症患者,根据患者住ICU期间是否发生VTE分为VTE组和无VTE组,...     

Risk factors for failure of heparin thromboprophylaxis in patients with acute traumatic spinal cord injury

Venous thromboembolism (VTE) is a well-recognized complication of Acute Traumatic Spinal Cord Injury (ATSCI). Despite prophylaxis by heparins, VTE occurs in a substantial number of ATSCI patients without an obvious explanation. In this matched case-control study we examined whether thrombophilia and other risk factors are associated with failure of thromboprophylaxis.Cases and controls receiving heparin thromboprophylaxis were selected from consecutively admitted ATSCI patients. Patients who developed a new, objectively confirmed, symptomatic VTE despite prophylaxis at hospital were matched by gender, age, level and mechanism of ATSCI with 2-3 controls without VTE. Patients were interviewed about VTE risk factors and tested for factor V Leiden (FVL), prothrombin G20210A (PT), methylenetetrahydrofolate reductase C677T homozygosity (MTHFR), lupus anticoagulant, homocysteine (Hcy) and plasma factor VIII (FVIII) levels.Twenty-two patients with new VTE episodes and 64 controls were ascertained. The total number of gene alterations for MTHFR, FVL and PT or elevated levels of Hcy or FVIII was significantly more common in patients compared to controls (82% vs. 48%, p = 0.006). Multiple logistic regression proved the PT mutation, a positive family history of thrombosis and elevated levels of either FVIII or Hcy to be predictors of thrombosis.

Conclusion

A positive family history of VTE, carriership of the prothrombin mutation and elevated FVIII or Hcy levels were significantly associated with failure to prevent VTE by heparin therapy following ATSCI. Testing for thrombophilia in patients with ATSCI and possibly a more intense thromboprophylactic regimen seem desirable but need to be verified by a prospective study.     

Incidence and risk factors associated with in-hospital venous thromboembolism after aneurysmal subarachnoid hemorrhage

Our purpose was to determine the incidence and risk factors associated with in-hospital venous thromboembolism (VTE) in patients with aneurysmal subarachnoid hemorrhage (aSAH). The Nationwide Inpatient Sample database was queried from 2002 to 2010 for hospital admissions for subarachnoid hemorrhage or intracerebral hemorrhage and either aneurysm clipping or coiling. Exclusion criteria were age <18, arteriovenous malformation/fistula diagnosis or repair, or radiosurgery. Primary outcome was VTE (deep vein thrombosis [DVT] or pulmonary embolus [PE]). Multivariate logistic regression was used to assess association between risk factors and VTE. Secondary outcomes were in-hospital mortality, discharge disposition, length of stay and hospital charges. A total of 15,968 hospital admissions were included. Overall rates of VTE (DVT or PE), DVT, and PE were 4.4%, 3.5%, and 1.2%, respectively. On multivariate analysis, the following factors were associated with increased VTE risk: increasing age, black race, male sex, teaching hospital, congestive heart failure, coagulopathy, neurologic disorders, paralysis, fluid and electrolyte disorders, obesity, and weight loss. Patients that underwent clipping versus coiling had similar VTE rates. VTE was associated with pulmonary/cardiac complication (odds ratio [OR] 2.8), infectious complication (OR 2.8), ventriculostomy (OR 1.8), and vasospasm (OR 1.3). Patients with VTE experienced increased non-routine discharge (OR 3.3), and had nearly double the mean length of stay (p < 0.001) and total inflation-adjusted hospital charges (p < 0.001). To our knowledge, this is the largest study evaluating the incidence and risk factors associated with the development of VTE after aSAH. The presence of one or more of these factors may necessitate more aggressive VTE prophylaxis.