(1/2331) Inherited prothrombotic risk factors and cerebral venous thrombosis.
Fifteen patients with cerebral venous thrombosis were ascertained retrospectively. Their case notes were reviewed, and stored or new blood was assayed for factor V Leiden (FVL) mutation, prothrombin gene mutation 20201A, and 5,10 methylene tetrahydrofolate reductase (MTHFR) C677T mutation. A clinical risk factor was identified in 13 patients--the oral contraceptive pill (5), puerperium (1), HRT (1), mastoiditis (1), dehydration (1), lumbar puncture and myelography (1), carcinoma (1), lupus anticoagulant (2). In addition, two patients had the FVL mutation and five (one of whom also had the FVL mutation) were homozygous for the MTHFR mutation. The latter showed a higher than expected frequency compared to 300 healthy controls from South Wales (OR 3.15.95% Cl 1.01-9.83). No patient had the prothrombin 20201A mutation. Two patients died and three had a monocular visual deficit following anticoagulation (13) or thrombolytic (2) treatment, but there was no association between the presence of a primary prothrombotic risk factor and outcome. These results confirm the importance of investigating patients for both clinical predisposing factors and primary prothrombotic states. (+info)
(2/2331) Aetiologies and prognosis of Chinese patients with deep vein thrombosis of the lower extremities.
Deep vein thrombosis (DVT) of the lower extremities is not frequently encountered in Oriental patients. We investigated its aetiology and prognosis in 143 patients (65 males, 78 females), presenting to the National Taiwan University Hospital over 4.3 years, diagnosed by colour Doppler ultrasonography. Swelling and pain of the lower extremities were the most frequent presenting symptoms. The left femoropopliteal veins were more frequently involved than other parts of the lower extremities. In these patients, malignancy with or without intravenous catheterization was the most frequent cause (39 patients, 27%). Other common aetiologies included coagulopathy (29 patients, 20%), immobilization (24 patients, 17%) and catheter-related (13 patients, 9%). No definite aetiology could be determined in 37 patients (26%). During follow-up, 27 patients (19%) died, mostly with malignancy. Pulmonary embolism was noted in 16 patients and was not significantly directly related to death. Compared to similar studies in Caucasian patients, there were significant differences in the aetiology of DVT, with malignancy and coagulopathy more common in these Chinese patients. (+info)
(3/2331) Venous duplex scanning of the leg: range, variability and reproducibility.
Despite the many studies on venous haemodynamics using duplex, only a few evaluated the normal values, variability and reproducibility. Therefore, the range and variability of venous diameter, compressibility, flow and reflux were measured. To obtain normal values, 42 healthy individuals (42 limbs, 714 vein segments) with no history of venous disease were scanned by duplex. To determine the reproducibility the intra-observer variability was measured in 11 healthy individuals (187 vein segments) and the inter-observer variability in 15 healthy individuals (255 vein segments) and 13 patients (169 vein segments) previously diagnosed with deep venous thrombosis. Of the 714 normal vein segments, 708 (99%) were traceable, including the crural veins. Of the traceable vein segments, 675 (95%) were compressible and in 696 (98%) flow was present. Of the 42 common femoral vein segments, in 25 (60%) the reflux duration exceeded 1.0 s, but in the other proximal vein segments the reflux duration was less than 1.0 s (95% confidence interval 3.0-10.0). With the exception of the distal long saphenous vein, in the distal vein segments the reflux duration was less than 0.5 s (95% confidence interval 3.5-8.2). The coefficient of variation of the diameter measurements ranged from 14 to 50% and that of the reflux measurements from 28 to 60%. The kappa-coefficient of the inter-observer variability in the classification of compressibility measurements in the patients was 0. 77 and that of the reflux measurements was 0.86. This study shows that almost all veins were compressible in healthy individuals, except the distal femoral veins. In healthy individuals the duration of reflux of the proximal veins was less than 1.0 s and in the distal veins it was less than 0.5 s. The inter-observer variability of the reflux and compressibility measurements in the patients was good. (+info)
(4/2331) G20210A mutation in prothrombin gene and risk of myocardial infarction, stroke, and venous thrombosis in a large cohort of US men.
BACKGROUND: A single base pair mutation in the prothrombin gene has recently been identified that is associated with increased prothrombin levels. Whether this mutation increases the risks of arterial and venous thrombosis among healthy individuals is controversial. METHODS AND RESULTS: In a prospective cohort of 14 916 men, we determined the prevalence of the G20210A prothrombin gene variant in 833 men who subsequently developed myocardial infarction, stroke, or venous thrombosis (cases) and in 1774 age- and smoking status-matched men who remained free of thrombosis during a 10-year follow-up (control subjects). Gene sequencing was used to confirm mutation status in a subgroup of participants. Overall, carrier rates for the G20210A mutation were similar among case and control subjects; the relative risk of developing any thrombotic event in association with the 20210A allele was 1.05 (95% CI, 0.7 to 1.6; P=0.8). We observed no evidence of association between mutation and myocardial infarction (RR=0.8, P=0.4) or stroke (RR=1.1, P=0.8). For venous thrombosis, a modest nonsignificant increase in risk was observed (RR=1.7, P=0.08) that was smaller in magnitude than that associated with factor V Leiden (RR=3.0, P<0. 001). Nine individuals carried both the prothrombin mutation and factor V Leiden (5 controls and 4 cases). One individual, a control subject, was homozygous for the prothrombin mutation. CONCLUSIONS: In a large cohort of US men, the G20210A prothrombin gene variant was not associated with increased risk of myocardial infarction or stroke. For venous thrombosis, risk estimates associated with the G20210A mutation were smaller in magnitude than risk estimates associated with factor V Leiden. (+info)
(5/2331) Low-molecular-weight heparin in outpatient treatment of DVT.
Patients with a diagnosis of acute deep venous thrombosis have traditionally been hospitalized and treated with unfractionated heparin followed by oral anticoagulation therapy. Several clinical trials have shown that low-molecular-weight heparin is at least as safe and effective as unfractionated heparin in the treatment of uncomplicated deep venous thrombosis. The use of low-molecular-weight heparin in an outpatient program for the management of deep venous thrombosis provides a treatment alternative to hospitalization in selected patients. Use of low-molecular-weight heparin on an outpatient basis requires coordination of care, laboratory monitoring, and patient education and participation in treatment. Overlapping the initiation of warfarin permits long-term anticoagulation. Advantages include a decreased incidence of heparin-induced thrombocytopenia and fewer episodes of bleeding complications. Future clinical trials evaluating the safety and efficacy of low-molecular-weight heparin in the treatment of complicated deep venous thrombosis will further define appropriate indications for use and strategies for outpatient management. (+info)
(6/2331) Right atrial bypass grafting for central venous obstruction associated with dialysis access: another treatment option.
PURPOSE: Central venous obstruction is a common problem in patients with chronic renal failure who undergo maintenance hemodialysis. We studied the use of right atrial bypass grafting in nine cases of central venous obstruction associated with upper extremity venous hypertension. To better understand the options for managing this condition, we discuss the roles of surgery and percutaneous transluminal angioplasty with stent placement. METHODS: All patients had previously undergone placement of bilateral temporary subclavian vein dialysis catheters. Severe arm swelling, graft thrombosis, or graft malfunction developed because of central venous stenosis or obstruction in the absence of alternative access sites. A large-diameter (10 to 16 mm) externally reinforced polytetrafluoroethylene (GoreTex) graft was used to bypass the obstructed vein and was anastomosed to the right atrial appendage. This technique was used to bypass six lesions in the subclavian vein, two lesions at the innominate vein/superior vena caval junction, and one lesion in the distal axillary vein. RESULTS: All patients except one had significant resolution of symptoms without operative mortality. Bypass grafts remained patent, allowing the arteriovenous grafts to provide functional access for 1.5 to 52 months (mean, 15.4 months) after surgery. CONCLUSION: Because no mortality directly resulted from the procedure and the morbidity rate was acceptable, this bypass grafting technique was adequate in maintaining the dialysis access needed by these patients. Because of the magnitude of the procedure, we recommend it only for the occasional patient in whom all other access sites are exhausted and in whom percutaneous dilation and/or stenting has failed. (+info)
(7/2331) Evaluation of lidocaine as an analgesic when added to hypertonic saline for sclerotherapy.
PURPOSE: The efficacy of sclerosing agents for the treatment of telangiectasias and reticular veins is well established. The injection of these agents is often associated with pain, and it is not uncommon for sclerotherapists to include lidocaine with the sclerosants in an attempt to reduce the pain associated with treatment. However, there are concerns that this may reduce the overall efficacy of the treatment because of dilution of the sclerosant. Patient comfort and overall outcome associated with treatment using HS with lidocaine (LIDO) versus that using HS alone was compared. METHODS: Forty-two patients were prospectively entered into the study and randomized blindly to sclerotherapy with 23.4% HS or 19% LIDO. Study subjects and treating physicians were blinded to the injection solution used. Injection sites were chosen for veins ranging in size from 0.1 to 3 mm. Photographs of the area to be treated were taken, and the patients rated their pain. They were then observed at regular intervals for four months, and clinical data was collected. Thirty-five subjects completed the full follow-up period, and photographs of the injected area were taken again. Three investigators blinded to the treatment assignment then evaluated the photographs and scored the treatment efficacy according to a standardized system. RESULTS: In the HS group, 61.9% (13 of 21) patients rated their pain as none or mild, whereas 90.5% (19 of 21) of patients in the LIDO group had no or mild discomfort. This difference is significant, with a P value of.034. There was no difference in the overall efficacy of treatment between the two groups. The groups had similar rates of vein thrombosis and skin necrosis. CONCLUSION: Although lidocaine is often used with sclerosing agents, there are no previous reports in the literature to evaluate its effectiveness in reducing the pain experienced by the patient. In this study, patients receiving LIDO experienced significantly less discomfort at the time of injection than patients who received HS alone. There were no differences in the effectiveness of treatment or in the incidence of complications between the two groups. (+info)
(8/2331) Relief of obstructive pelvic venous symptoms with endoluminal stenting.
PURPOSE: To select patients for percutaneous transluminal stenting of chronic postthrombotic pelvic venous obstructions (CPPVO), we evaluated the clinical symptoms in a cohort of candidates and in a series of successfully treated patients. METHODS: The symptoms of 42 patients (39 women) with CPPVO (38 left iliac; average history, 18 years) were recorded, and the venous anatomy was studied by means of duplex scanning, subtraction venography, and computed tomography or magnetic resonance imaging. Successfully stented patients were controlled by means of duplex scanning and assessment of symptoms. RESULTS: The typical symptoms of CPPVO were reported spontaneously by 24% of patients and uncovered by means of a targeted interview in an additional 47%. Of 42 patients, 15 had venous claudication, four had neurogenic claudication (caused by dilated veins in the spinal canal that arise from the collateral circulation), and 11 had both symptoms. Twelve patients had no specific symptoms. Placement of a stent was found to be technically feasible in 25 patients (60%), was attempted in 14 patients, and was primarily successful in 12 patients. One stent occluded within the first week. All other stents were fully patent after a mean of 15 months (range, 1 to 43 months). Satisfaction was high in the patients who had the typical symptoms, but low in those who lacked them. CONCLUSION: Venous claudication and neurogenic claudication caused by venous collaterals in the spinal canal are typical clinical features of CPPVO. We recommend searching for these symptoms, because recanalization by means of stenting is often feasible and rewarding. (+info)