Deep venous thrombosis and pulmonary embolism in bilateral lower-extremity amputee patients.

OBJECTIVE: To determine the incidence of deep venous thrombosis and pulmonary emboli and the value of an inferior vena cava filter in patients with bilateral lower-extremity amputations, and to determine the incidence of pulmonary emboli after filter placement. DESIGN: Retrospective study with a follow-up of 3 to 64 months. SETTING: Inner-city university hospital. PATIENTS: Twenty-seven consecutive patients with bilateral lower-limb amputation. RESULTS: Age, sex, and race were assessed, and had no impact on the incidence of pulmonary embolus in these patients with lower-extremity amputation. CONCLUSION: No clinical objective evidence of pulmonary emboli occurred after placement of an inferior vena caval filter.     

Management of deep venous thrombosis and pulmonary embolism

The management of deep venous thrombosis (DVT) and pulmonary embolism (PE) is changing dramatically. The US Food and Drug Administration has approved outpatient treatment of DVT with the low-molecular-weight heparin enoxaparin as a bridge to warfarin. Warfarin use is improved by avoiding loading doses and by recognizing previously unappreciated interactions and potentiation with commonly used medications such as acetaminophen. The importance of isolated calf and upper-extremity venous thromboses has been validated, so that patients with these conditions routinely undergo anticoagulation. Risk stratification for PE is becoming more sophisticated because practitioners now assess right ventricular function (usually by echocardiography) instead of relying solely on systemic arterial blood pressure and heart rate to determine prognosis. Among patients with massive DVT or hemodynamically unstable PE, thrombolysis, thrombectomy, and embolectomy (often performed in an interventional angiography laboratory) are being used with increasing skill and improved outcomes.     

Controversies in pulmonary embolism and deep venous thrombosis

The diagnosis of venous thromboembolic disease, and pulmonary embolism in particular, remains problematic. Physicians should strongly consider empiric anticoagulation if the best available diagnostic tests are inconclusive, because treatment is usually safe and successful. Twice-daily subcutaneous low-molecular-weight heparin, dosed without monitoring, may eventually replace standard heparin for most treatment of venous thromboembolism, but it is not yet labeled for the treatment of pulmonary embolism. Deep venous thromboembolism and pulmonary embolism should be treated with anticoagulants rather than inferior vena cava filters, even in oncology patients, unless anticoagulation is contraindicated; if so, when the contraindication remits, anticoagulation should be employed. The most effective prophylaxis of venous thromboembolism in at-risk patients should be used, with prolonged duration if evidence from clinical trials supports efficacy and safety. Low-dose warfarin should be used to prevent venous thrombosis and indwelling central venous catheter thrombosis in patients with cancer.     

Diagnosis of deep venous thrombosis and pulmonary embolism. The tests and their limitations

Pulmonary embolism and venous thrombosis are ubiquitous diseases with significant morbidity and mortality and for which successful although risky treatments are available. Accurate diagnosis is therefore necessary and requires testing beyond the physical examination and history. The number of tests proposed over the years compared with the number in current use attests to the problems with the methods. The more definitive tests are also more invasive, riskier, and more expensive. Individual experience in performance and interpretation of the available tests is of great importance in achieving accurate results, and thus the best scheme for investigation of the patient varies from institution to institution. The most accepted and practiced scheme would involve contrast venography as the initial and final test for suspected venous thrombosis, and pulmonary perfusion imaging (with use of chest radiography in all instances and ventilation imaging in most instances) as the screening test for pulmonary embolism, followed by pulmonary angiography when the scan is not definitive or the clinical picture is divergent from the scan results.     

Deep venous thrombosis.

Venous thrombosis involving the deep veins is a major US health problem that affects over 2.5 million people annually. The most serious complication of a deep venous thrombosis (DVT) is pulmonary embolism (PE), which is associated with 50,000 to 200,000 deaths each year. DVT and PE are often silent and difficult to detect by clinical examination; however, DVT rarely occurs in the absence of risk factors. This article reviews normal venous anatomy and discusses the etiology of DVT, its clinical manifestations, and diagnosis. Then it reviews treatment of DVT, highlighting the nurse's role. A discussion of DVT prophylaxis based on patient risk follows.     

Deep venous thrombosis and pulmonary embolism as a complication of bed rest for low back pain

A case of bilateral lower extremity deep venous thrombosis and pulmonary embolism as a complication of bed rest prescribed for an acute low back pain episode is presented. A 29-year-old woman with low back pain was prescribed more than 2 weeks of bed rest, during which she developed progressive bilateral lower extremity complaints that were ascribed to nerve root irritation. Her symptoms were initially treated with physical therapy and epidural steroid injections. A Doppler examination and ventilation-perfusion scan revealed extensive deep venous thromboses and mismatches consistent with pulmonary embolism. This case illustrates an unusual extraspinal source of lower extremity symptoms associated with low back pain and further supports the role of early mobilization in the treatment of back pain.     

Diagnostic role of ED ultrasound in deep venous thrombosis and pulmonary embolism.

Proximal deep venous thrombosis (DVT), which may lead to pulmonary embolism (PE), is one of the serious and underrecognized causes of lower extremity pain and swelling. The diagnosis of DVT requires a confirmatory objective test because clinical signs and symptoms are unreliable. Assessment of thigh vein compressibility with real-time ultrasound is an accurate test for DVT that may be performed rapidly at the bedside. Although unproven, we propose that wider use of this test in the emergency department by emergency physicians might increase the diagnosis of DVT, prevent PE, and reduce utilization of other more costly and invasive diagnostic tests. Evaluation of DVT by compression ultrasound may also be incorporated in the diagnostic workup of suspected PE. In the case of a nondiagnostic ventilation/perfusion scan, demonstration of proximal DVT by ultrasound represents a likely source of PE and an indication for anticoagulation, eliminating the need for pulmonary angiography. In the critically ill patient whose presentation is consistent with massive PE, one rapid approach to the diagnosis may be to combine transthoracic echocardiography with lower extremity ultrasound.     

Determining the clinical probability of deep venous thrombosis and pulmonary embolism

Deep venous thrombosis and pulmonary embolism are potentially life-threatening problems that present diagnostic challenges. To employ objective diagnostic tests in an efficient, safe, and cost-effective manner, the clinical probability of these disorders should be estimated before testing. A number of clinical prediction rules are available for suspected deep venous thrombosis, while there are three major prediction rules available for estimating the probability of pulmonary embolism. Recent modifications of the Wells score for deep venous thrombosis simplify its use. Although the Wells score for pulmonary embolism is commonly used, two other rules are useful for this disorder as well. This review summarizes the clinical prediction rules and gives recommendations about their application.     

The venous stasis syndrome after deep venous thrombosis or pulmonary embolism: a population-based study

OBJECTIVES: To estimate the incidence and determine predictors of venous stasis syndrome and venous ulcers after deep venous thrombosis and pulmonary embolism. PATIENTS AND METHODS: This population-based retrospective cohort study reviewed medical records of 1527 patients with incident deep venous thrombosis or pulmonary embolism between 1966 and 1990. We recorded baseline characteristics, event type (deep venous thrombosis with or without pulmonary embolism or pulmonary embolism alone), leg side and site of deep venous thrombosis (proximal with or without distal deep venous thrombosis vs distal deep venous thrombosis alone), and venous stasis syndrome and venous ulcer. RESULTS: Two hundred forty-five patients developed venous stasis syndrome. One-year, 5-year, 10-year, and 20-year cumulative incidence rates were 7.3%, 14.3%, 19.7%, and 26.8%, respectively. By 20 years the cumulative incidence of venous ulcers was 3.7%. Patients with deep venous thrombosis with or without pulmonary embolism were 2.4-fold (95% confidence interval, 1.7-fold-3.2-fold) more likely to develop venous stasis syndrome than patients with pulmonary embolism and no diagnosed deep venous thrombosis. In patients aged 40 years or younger with proximal compared with distal-only deep venous thrombosis, venous stasis syndrome was 3.0-fold more likely (95% confidence interval, 1.6-fold-4.7-fold). In patients with unilateral leg deep venous thrombosis, venous stasis syndrome usually developed in the concordant leg (P < .001). There was a 30% (95% confidence interval, 2%-62%) increased risk for venous ulcer per decade of age at the incident venous thromboembolism. CONCLUSIONS: The cumulative incidence of venous stasis syndrome continues to increase for 20 years after venous thromboembolism. Pulmonary embolism alone is less likely to cause venous stasis syndrome.     

深静脉血栓形成

一、临床特点(一)定义·深静脉血栓形成(deepvenousthrombosis,DVT)———是指纤维蛋白、血小板、红细胞等血液成分在深静脉血管腔内形成凝血块(血栓)———DVT多发生于下肢深静脉,临床比较常见,引起肺血栓栓塞症(PTE)的血栓主要来源于下肢DVT(二)危险因素·血液的高凝状态——     

Prophylaxis for deep venous thrombosis and pulmonary embolism in the surgical patient

The fifth American College of Chest Physicians Consensus Conference on Antithrombotic Therapy provides the most up-to-date guidelines for the prevention of deep venous thrombosis (DVT) and pulmonary embolism (PE) in the surgical patient (1). These recommendations have become a major guideline for clinicians managing patients in the perioperative period. Despite these recommendations, there remains a concern for balancing the risk of major postoperative bleeding with the benefit of preventing thrombosis. In an attempt to resolve this issue, clinicians have requested clear-cut guidelines for identification of high-risk groups for whom prophylaxis must be used. This article will review the etiology, risk-factor stratification, regimens of prophylaxis, and recommendations for prevention of postoperative DVT and PE.     

Deep vein thrombosis and pulmonary embolism in an ambulatory chronic stroke patient

Purpose: Deep vein thrombosis (DVT) is a well-known complication of stroke and frequently develops in acute stroke patients. Immobility in stroke patients increases the risk of DVT and pulmonary embolism (PE). The incidence of DVT in non-ambulatory stroke patients is more frequent than the incidence in ambulatory stroke patients. We report a case of DVT and PE in an ambulatory chronic stroke patient.

Method: Initial physical examination showed heat and swelling of hemiplegic leg. The patient was only able to ambulate with the assist of a monocane and a plastic leaf spring orthosis due to ankle dorsiflexor weakness. The patient was treated with anticoagulation and inferior vena cava filter placement.

Results: After long-term anticoagulation, follow-up studies revealed satisfactory resolution of DVT and PE.

Conclusions: We present a case of DVT and PE which developed during the chronic stage of stroke, 2 years from the onset of stroke, and review the cause of DVT.     

Deep vein thrombosis and pulmonary embolism in an ambulatory chronic stroke patient

Purpose:?Deep vein thrombosis (DVT) is a well-known complication of stroke and frequently develops in acute stroke patients. Immobility in stroke patients increases the risk of DVT and pulmonary embolism (PE). The incidence of DVT in non-ambulatory stroke patients is more frequent than the incidence in ambulatory stroke patients. We report a case of DVT and PE in an ambulatory chronic stroke patient.

Method:?Initial physical examination showed heat and swelling of hemiplegic leg. The patient was only able to ambulate with the assist of a monocane and a plastic leaf spring orthosis due to ankle dorsiflexor weakness. The patient was treated with anticoagulation and inferior vena cava filter placement.

Results:?After long-term anticoagulation, follow-up studies revealed satisfactory resolution of DVT and PE.

Conclusions:?We present a case of DVT and PE which developed during the chronic stage of stroke, 2 years from the onset of stroke, and review the cause of DVT.