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[Modern treatment of deep vein thrombosis and pulmonary embolism].
Renczes, J, Lindhoff-Last, E
Der Internist. 2019;(6):644-655
Abstract
Virchow's triad has been known for a 100 years. The development of therapeutic possibilities during this time was enormous. Today anticoagulant therapy is much more differentiated. Four new oral substances have replaced the traditional treatment with vitamin K antagonists in angiology. A standardized dosage is available. The monitoring of the coagulation parameters is no longer necessary, but it is important to monitor renal function. Direct oral anticoagulants are approved for the treatment of venous thrombosis and pulmonary embolism, but not during pregnancy or in children. Severe bleeding complications, especially intracerebral bleeding, are less common. The incidence of venous thromboembolism is still high. Obesity and cancer are of particular importance. The "therapeutic pact" with the patient requires that physicians master the art of "talking medicine".
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Deep vein thrombosis during long-term surveillance of patients with liver transplantation.
Balaceanu, A
Irish journal of medical science. 2019;(4):1191-1193
Abstract
BACKGROUND In the European Liver Transplant Registry, there are 137,863 liver transplantations recorded. Forty-one percent of patients survived 20 years after liver transplantation in the European countries. From 1988, when the US database for liver transplantation was created, to 2006, there are more than 56,000 liver transplants. Almost 80% of the liver transplant recipients survived 5 years after transplantation. The incidence of deep vein thrombosis (DVT) in the European population is 70-140/100.000 person-years. Cancer, paresis, immobilization, thrombophilia, inflammatory bowel disease, replacement hormonal or contraceptive therapies are associated with an increased risk of occurrence DVT or complications. The incidence of DVT in long-term surveillance of liver transplant recipients is unknown. Immunosuppressive therapy, thrombophilia abnormalities, hepatitis C and hepatocellular carcinoma recurrence, renal insufficiency, malignant tumours, obesity and diabetes were associated with DVT in long-term post-liver transplantation. The reported maximum time between liver transplantation and DVT was 210 days. AIM: The aim of the study is to update existing data in the literature regarding the occurrence and management of deep vein thrombosis in liver transplant patients over the long-term surveillence period. CONCLUSIONS There are no specific guideline recommendations regarding acute DVT treatment in long-term surveillance after liver transplantation. Low molecular weight heparin (LMWH), unfractionated heparin (UFH) and vitamin K antagonist (VKA) are the anticoagulants used in specific complications post-transplantation. The safety and the efficacy of direct anticoagulants in liver transplantation recipients need to be assessed in future trials. Given that long-term survival of liver transplantation is much improved, complications associated with transplantation and ageing require appropriate cardiovascular guidelines.
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Is pharmacological anticoagulant prophylaxis necessary for adolescent idiopathic scoliosis surgery?
Kochai, A, Cicekli, O, Bayam, L, Türker, M, Sariyilmaz, K, Erkorkmaz, Ü
Medicine. 2019;(29):e16552
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Abstract
We report the outcomes of mechanical prophylaxis and chemoprophylaxis in patients who underwent elective surgery for idiopathic adolescent scoliosis (AIS).We retrospectively studied the patients who underwent posterior spinal instrumentation for AIS. The patients were divided into three groups: Group A low-molecular-weight heparin (LMWH) started at 8 hours after surgery; Group B LMWH started at 24 hr after surgery; Group C did not receive chemoprophylaxis. The data about wound oozing, need for transfusion, preoperative and postoperative hemoglobin level, length of stay in hospital, interval from the surgery to removal of closed suction drainage tube, postoperative blood loss from closed suction drain, deep venous thrombosis (DVT), and pulmonary embolism (PE) were investigated.The mean age and Lenke classification for all the groups were similar. No DVT or PE was detected in any group. The mean blood loss from the drain was higher in Group A (400 mL) and Group B (450 mL) when compared to Group C (150 mL) (P = .001). There were more wound oozing in Groups A (5) and B (6) than in Group C (3) (P = .585). Three patients in Group B, 3 patients in Group A, and no patient in Group C had superficial infections. However, there was no statistical difference between the groups (P = .182). Postoperative hospital stay was significantly longer in Groups A (6 days) and B (6 days) then in Group C (5 days) (P = .001).Our current study claims that chemoprophylaxis is not necessary for the patients without risk factors after AIS surgery. Early mobilization and mechanoprophylaxis represents adequate prophylaxis in addition to pain management and well hydration in patients' routine treatment. The complications of chemoprophylaxis are not correlated to the initiation time of prophylaxis.
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Patient adherence to rivaroxaban in deep vein thrombosis, a cohort study in Switzerland: quantitative results.
Dotta-Celio, J, Alatri, A, Locatelli, I, Salvi, M, Bugnon, O, Schneider, MP, Mazzolai, L
International journal of clinical pharmacy. 2019;(6):1625-1633
Abstract
Background Direct oral anticoagulants (DOACs) have the advantage of being administered orally at a fixed dose without laboratory monitoring, in contrast to the frequent international normalized ratio measurements used to adjust for vitamin K antagonists dosing. Rivaroxaban, has a short half-life. The anticoagulation effect rapidly decreases if medication adherence is suboptimal. Objective The purpose of this quantitative study (called RIVA) is to longitudinally describe adherence to rivaroxaban (implementation and persistence) in patients with deep vein thrombosis (DVT). Setting The community pharmacy of the Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland in collaboration with the angiology division of the Lausanne University Hospital (CHUV). Methods This is an observational study. Patients received rivaroxaban for 3 or 6 months: 15 mg twice a day during the first 3 weeks and then 20 mg once a day until the end of the treatment. Adherence was measured using electronic monitoring. Implementation and adherence were modelled using a generalized estimating equation model. Persistence was represented using a Kaplan-Meier survival curve. Main outcome measure Medication adherence (implementation and persistence). Results Thirty-one consecutive patients were included (68% male, mean age: 47 years old). The collected adherence data consisted of 57 inter-visit phases, 2899 electronic monitoring openings and a median follow-up of 92 days (IQR: 87; 100). Implementation to rivaroxaban was initially high [96.3 (92.8; 98.1)] but decreased during the first 3 weeks, until it reached 89.3 (76.0; 95.6). After the switch from twice a day 15 mg to a once a day 20 mg regimen, implementation increased again and remained stable [95.4 (92.2; 97.3)] for 90 days. Four patients who experienced adverse events discontinued the treatment before the end of the study and were considered non-persistent (clinically appropriate discontinuation). Conclusion Adherence to rivaroxaban in deep vein trombosis is high in persistent patients. Discontinuation is related to rivaroxaban adverse effects/toxicity. Implementation should be reinforced during the twice a day-phase, and this first 3-week experience should help patients and healthcare professionals choose the best timing for the once a day phase.
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Pharmacomechanical Catheter-Directed Thrombolysis in Acute Femoral-Popliteal Deep Vein Thrombosis: Analysis from a Stratified Randomized Trial.
Kearon, C, Gu, CS, Julian, JA, Goldhaber, SZ, Comerota, AJ, Gornik, HL, Murphy, TP, Lewis, L, Kahn, SR, Kindzelski, AL, et al
Thrombosis and haemostasis. 2019;(4):633-644
Abstract
BACKGROUND AND OBJECTIVES The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial reported that pharmacomechanical catheter-directed thrombolysis (PCDT) did not reduce post-thrombotic syndrome (PTS), but reduced moderate-to-severe PTS and the severity of PTS symptoms. In this analysis, we examine the effect of PCDT in patients with femoral-popliteal deep vein thrombosis (DVT) (without involvement of more proximal veins). PATIENTS AND METHODS Within the ATTRACT trial, 300 patients had DVT involving the femoral vein without involvement of the common femoral or iliac veins and were randomized to receive PCDT with anticoagulation or anticoagulation alone (no PCDT). Patients were followed for 24 months. RESULTS From 6 to 24 months, between the PCDT versus no PCDT arms, there was: no difference in any PTS (Villalta scale ≥ 5: risk ratio [RR] = 0.97; 95% confidence interval [CI], 0.75-1.24); moderate-or-severe PTS (Villalta scale ≥ 10: RR = 0.93; 95% CI, 0.57-1.52); severity of PTS scores; or general or disease-specific quality of life (p > 0.5 for all comparisons). From baseline to both 10 and 30 days, there was no difference in improvement of leg pain or swelling between treatment arms. From baseline to 10 days, major bleeding occurred in three versus none (p = 0.06) and any bleeding occurred in eight versus two (p = 0.032) PCDT versus no PCDT patients. Over 24 months, recurrent venous thromboembolism occurred in 16 PCDT and 12 no PCDT patients (p = 0.24). CONCLUSION In patients with femoral-popliteal DVT, PCDT did not improve short- or long-term efficacy outcomes, but it increased bleeding. Therefore, PCDT should not be used as initial treatment of femoral-popliteal DVT. (NCT00790335).
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Genetic polymorphisms in the FVII gene is associated with lower extremity deep venous thrombosis: A case-control study.
Liu, JW, Chen, DQ
Journal of cellular biochemistry. 2018;(8):6715-6722
Abstract
This study aims to explore the associations between FVII gene polymorphisms (R353Q, 5'F7, and -402G/A) and lower extremity deep venous thrombosis (LEDVT) in a Chinese Han population. LEDVT patients (153) and healthy people (174) were, respectively, as case and control groups and evaluated related biochemical indicators. Gene polymorphisms of R353Q, 5'F7, and -402G/A of FVII, serum FVII level, antithrombin activity, plasma fibrinogen content, and plasma D-dimer (D-D) level were determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP), ELISA, chromogenic substrate assay, coagulating assay, and Immunoturbidimetry assay, respectively. Compared with the control group, the case group had a higher level of body mass index (BMI), glucose, and fibrinogen, and lower level of total cholesterol (TC). Notable differences were found in GG genotype, G and A alleles, as well as distribution of recessive model of -402G/A. The serum FVII level of GG genotype was higher than that of GA and AA genotypes. FIB and D-D had a higher level had a lower level in GG genotype when compared with GA and AA genotypes. Smoking, drinking, serum FVII level, and -402G/A-GG were the independent risk factors for LEDVT. This study demonstrates that -402G/A of FVII may be a risk factor for LEDVT patients in a Chinese Han population.
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Apixaban-induced subdural bleeding: case presentation and literature review.
Alayad, E, Khairy, S, Aloraidi, A
BMJ case reports. 2018
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Abstract
Apixaban is a factor Xa inhibitor which is a non-vitamin K dependent oral anticoagulant known tocause the lowest rate of intracranial bleeding among the same kind of inibitors. In this paper, we report a rare case in a 60-year-old man with a history of hypertension and oligodendroglioma on apixaban for deep venous thrombosis who presented to our hospital with decreased level of consciousness and slurred speech with rapid deterioration. We highlight the risk of subdural bleeding requiring immediate neurosurgical intervention due to apixaban, with literature review.
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Rationale, design, and protocol of a randomized controlled trial of the safety and efficacy of dabigatran etexilate versus dose-adjusted warfarin in patients with cerebral venous thrombosis.
Ferro, JM, Dentali, F, Coutinho, JM, Kobayashi, A, Caria, J, Desch, M, Fraessdorf, M, Huisman, H, Diener, HC
International journal of stroke : official journal of the International Stroke Society. 2018;(7):766-770
Abstract
Rationale To prevent recurrent venous thrombotic events after acute cerebral venous or dural sinus thrombosis, guidelines recommend long-term oral anticoagulation with vitamin K antagonists. Non-vitamin K oral anticoagulant experience in cerebral venous or dural sinus thrombosis is limited to case reports and series. Aim To compare dabigatran with dose-adjusted warfarin in patients with cerebral venous or dural sinus thrombosis for the prevention of recurrent venous thrombotic event. Sample size One hundred and twenty patients. Methods and design This study is a phase III, prospective, randomized, parallel-group, open-label, multicenter, exploratory trial with blinded endpoint adjudication. Patients with acute cerebral venous or dural sinus thrombosis after 5-15 days of treatment with parenteral heparin are randomized to either dabigatran etexilate 150 mg twice daily or dose-adjusted (international normalized ratio 2-3) warfarin (≤24 weeks). Study outcome The primary endpoint is a composite of patients with new venous thrombotic event (recurring cerebral venous or dural sinus thrombosis, deep venous thrombosis of any limb, pulmonary embolism, and major bleeding (International Society on Thrombosis and Hemostasis definition)) during the treatment period. Statistics will be descriptive (number and frequencies). Study timelines Inclusion started in December 2016. Final results are expected by the end of 2018. Discussion This exploratory trial is the first to compare vitamin K with non-vitamin K antagonists in cerebral venous or dural sinus thrombosis. It will provide evidence to guide physicians and patients in choosing oral anticoagulants to prevent venous thrombotic event after acute cerebral venous or dural sinus thrombosis. ClinicalTrials.gov number: NCT02913326.
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The relationship between gene polymorphism of MTRR A66G and lower extremity deep venous thrombosis.
Xu, J, Zhou, W
Hematology (Amsterdam, Netherlands). 2018;(10):828-832
Abstract
OBJECTIVE To investigate the relationship between gene polymorphism of MTRR A66G and lower extremity deep venous thrombosis (DVT). METHODS Two hundred and two patients with DVT as experimental group and 240 normal adults (control group) were enrolled in this study and white blood cells were collected, respectively. Polymorphism of the 66 loci in MTRR gene was detected by polymerase chain reaction-sequence-specific primers (PCR-SSP) in two groups. The frequency of genotype and allele distribution of each group was compared. RESULTS The frequency of AA, AG and GG genotypes in 66 sites of MTRR gene were 26.76%, 4 3.66% and 29.58% in DVT group and 43.57%, 44.28% and 12.14% in control group, respectively. There was no significant difference in the distribution frequency between two groups (χ = 3.2, P > .5). CONCLUSIONS The gene polymorphism of MTRR A66G may not be an independent genetic risk factor in DVT in China.
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Heparin promotes recanalization of venous thrombotic occlusions.
Poredos, P, Poredos, P, Jezovnik, MK
International angiology : a journal of the International Union of Angiology. 2018;(4):261-268
Abstract
Thrombosis is a consequence of disbalance between the procoagulant and fibrinolytic activity of blood and is frequently associated with chronic sequelae, which are the consequence of chronic occlusion of affected veins. Treatment of venous thrombosis should not be oriented in the prevention of thrombus progression and associated thromboembolic events, but also in stimulation of thrombolysis and recanalization of occluded veins, which are one of the most important preventive mechanisms of late sequelae, including post-thrombotic syndrome. The treatment of acute venous thrombosis (superficial and deep) is based on drugs with anticoagulant activity, like antagonists of vitamin K, heparins, and new oral anticoagulants. One of the most frequently used anticoagulant drugs is heparin, particularly the low molecular weight heparin (LMWH). It was shown that besides strong anticoagulant activity heparin has pro-fibrinolytic effects, which promote thrombolysis and recanalization of occluded veins. LMWH markedly increases tissue factor pathway inhibitor levels and a release of tissue plasminogen activator from vascular endothelium. Heparins are also capable of increasing the nitrogen oxide level, which is responsible for circulatory homeostasis.