Oedema in the lower limb of patients with chronic critical limb ischaemia (CLI).
(25/2331)
OBJECTIVE: approximately 70% of patients with chronic critical limb ischaemia (CLI) show clinical signs of oedema in the distal leg and foot. The primary aim of the present investigation was to quantify this oedema. In addition we investigated whether oedema formation could be due to deep venous thrombosis (DVT). METHODS: fifteen patients with unilateral CLI and oedema were studied, four males and 11 females, with a mean age of 77+/-10.3 years. Water displacement volumetry (WDV) was used to measure limb volume. Colour duplex ultrasound (CDU) and venous occlusion plethysmography (VOP) were applied to exclude functionally significant DVT. Blood chemistry was analysed to screen for some causative factors of generalised oedema formation. RESULTS: the mean volume of the limbs with CLI was 9% greater than the contralateral limbs (1279+/-325 ml vs. 1179+/-298 ml). None of the patients had functionally significant DVT. The mean plasma albumin concentration was reduced at 28.5+/-6.6 g/l. CONCLUSION: a significantly reduced plasma albumin concentration cannot be regarded as a causative factor, since the oedema is unilateral. The aetiology of oedema formation is probably multifactorial, and further investigations are under progress to elucidate relevant pathogenetic factors. (+info)
Cancer and venous thromboembolism: an overview.
(26/2331)
BACKGROUND AND OBJECTIVE: Although the relationship between malignant diseases and venous thromboembolism has been convincingly demonstrated, the clinical implications of this association still have to be thoroughly elucidated. The aim of this study was to review briefly the mechanisms by which cancer may induce the development of thrombosis and to analyze critically the most recent clinical advances in this field. EVIDENCE AND INFORMATION SOURCES: The material examined in the present review includes articles published in journals covered by the Science Citation Index and Medline . STATE OF THE ART: Neoplastic cells can activate the clotting system directly, thereby generating thrombin, or indirectly, by stimulating mononuclear cells to synthesize and express various procoagulants. Cancer cells and chemotherapeutic agents can injure endothelial cells, thereby intensifying hypercoagulability. Currently, primary prevention of venous thrombosis should be considered for cancer patients during and immediately after chemotherapy, when long-term indwelling central venous catheters are placed, during prolonged immobilization from any cause, and following surgical interventions. Secondary prevention of recurrent venous thromboses usually necessitates long-term anticoagulation. In some patients with cancer the condition is resistant to warfarin, and long-term adjusted high-dose heparin is required. The diagnosis of venous thromboembolism may help to uncover previously occult carcinoma by prompting a complete physical examination and a few routine tests. PERSPECTIVES: Further investigations are required to evaluate the cost-benefit ratio of extensive diagnostic screening for occult malignancy in all patients presenting with idiopathic venous thromboembolism, and to explore the potential of low molecular weight heparins for improving survival in patients with cancer. (+info)
Advances in imageology have improved the diagnostic yield of cerebral venous/sinus thrombosis (CVT). However, its management remains a challenge. The present study was carried out to study the role of heparin in CVT. Therapeutic outcome of 150 patients of puerperal CVT manifesting within one month of delivery or abortion, was analyzed. The diagnosis was supported by cranial computed tomography and/or angiography whenever required. Seventy three patients, 46 with non-haemorrhagic infarction and 27 with haemorrhagic infarction, received 2500 units of subcutaneous heparin, three times a day within 24 hours of hospitalization till 30th post partum day or symptomatic relief. Seventy seven patients during the same period, 50 with non-haemorrhagic infarction and 27 with haemorrhagic infarction, who did not receive heparin formed the control group. Repeat CT scans were done when indicated. Among the heparin group, 34 patients made full recovery. There were eight deaths, all among the patients with haemorrhagic lesion. In control group, only 14 patients recovered completely (P=<0.001) and 18 died (P=<0.001). There were no adverse effects of heparin. Low dose heparin is safe and efficacious in puerperal CVT, even in patients with haemorrhagic infarction. (+info)
Axillary vein thrombosis may occur on strenuous activity with a clinical picture similar to a simple strain. It carries significant morbidity but a good outcome is possible with early treatment. The aetiology, investigation, and treatment are discussed. (+info)
Venous thromboembolic disease and combined oral contraceptives: A re-analysis of the MediPlus database.
(29/2331)
In October 1995 the Committee on Safety of Medicines advised UK doctors and pharmacists that oral contraceptives containing desogestrel and gestodene were associated with double the risk of venous thromboembolic events (VTE) compared to pills containing other progestogens. In 1997 data was analysed from the MediPlus database of UK general practitioner records, which reported odds ratios for desogestrel and gestodene lower than that for levonorgestrel. Here the results of a more stringent nested case control analysis on the MediPlus database are reported. The study was larger and cases were verified. A crude incidence of idiopathic VTE was found amongst users of combined oral contraceptives of 4.6 per 10 000 exposed women years. Using levonorgestrel 150 microg + ethinyloestradiol 30 microg as reference, non-significant odds ratios of 1.1 (0.5-2.6) for desogestrel 150 microg + ethinyloestradiol 30 microg and 1.1 (0.5-2.4) for gestodene 75 microg + ethinyloestradiol 30 microg were found. The results of this study show no significant difference in risk between different formulations of combined oral contraceptive. (+info)
The differential risk of oral contraceptives: the impact of full exposure history.
(30/2331)
Previous discussions have indicated that the small increases of risk of venous thromboembolism (VTE) associated with newer combined oral contraceptives (third generation, containing desogestrel and gestodene) may be attributed to bias due to cohort effects. In a case-control analysis, this may produce an overestimate of risk of newer preparations. In 10 centres in Germany and the UK, the Transnational Study analysed data from 502 women aged 16-44 years with VTE, and from 1864 controls matched for 5-year age group and region. Information on lifetime exposure history from all subjects was added to the dataset used in previous analyses and entered into a Cox regression model with time-dependent covariates. Based on 17 622 continuous exposure episodes comprising 47 914 person-years of observation, the adjusted hazard ratio (equivalent to odds ratio, OR) of VTE for the comparison of current users of third-generation versus current users of second-generation (primarily levonorgestrel compounds) combined oral contraceptives was 0.8 (0.5 to 1.3). The OR obtained in standard case-control analysis had been 1.5 (1.1 to 2.1). Adjustment for past exposures includes more information and appears more valid than the standard cross-sectional analysis. Using this approach, the Transnational Study data show no evidence for an increased risk of VTE with third- compared with second-generation combined oral contraceptives. (+info)
Axillary vein transfer in trabeculated postthrombotic veins.
(31/2331)
PURPOSE: This study assessed whether axillary vein transfer can be successfully performed in trabeculated veins and whether patients with this severe form of postthrombotic syndrome can be helped by an aggressive approach. METHODS: A total of 102 axillary vein transfer procedures were carried out in 83 limbs with trabeculated veins. More than one venous segment was repaired in 38 limbs with a second axillary valve in 19, and a different technique was used in the remainder. The superficial and deep femoral veins were the most common target sites. "Bench repair" of leaky axillary valves was performed before the transfer in 32 cases. Venous stasis dermatitis or ulceration was present in 90% of the limbs. The operability rate and chance of successful valve reconstruction was high, even in the presence of severe venographic appearance. RESULTS: The actuarial transplant patency rate was 83% at 10 years. The actuarial freedom from recurrent ulceration rate was more than 60% at 10 years, similar to the results obtained in a matched group of axillary vein transfers to nontrabeculated veins. Severe preoperative ambulatory venous hypertension (venous filling time [VFT] of less than 5 seconds), which was present in 67% of patients, did not adversely affect outcome, but short VFTs that persisted after surgery did. VFT and VFI90 (venous filling index, air plethysmography) improved after valve transfer. Swelling disappeared or was significantly reduced in 55% of patients (11 of 20 patients) who had moderate or severe preoperative swelling. In 82% of patients (31 of 37 patients) who had mild or no preoperative swelling, the swelling remained stable after surgery, and in 18% of patients (6 of 37 patients), it became worse. Pain was significantly diminished in 70% of patients; 23% of patients with severe pain had complete resolution. CONCLUSION: Axillary vein transfer, in combination with other antirefluxive procedures when indicated, is safe, effective, and durable in patients with trabeculated veins and severe forms of postthrombotic syndrome. It may be considered as an option when conservative therapy or other types of surgery fail. (+info)
Diagnostic strategies in venous thromboembolism.
(32/2331)
BACKGROUND AND OBJECTIVE: Diagnosis of acute deep vein thrombosis (DVT) and of pulmonary embolism (PE) is often difficult: symptomatic patients are usually investigated employing several diagnostic tests, which should be appropriately selected and sequenced, taking into account their sensitivity, specificity, safety and cost. The objective of this paper is to evaluate the performance of the new diagnostic tests and their combination in rational diagnostic strategies. DESIGN AND METHODS: A literature review was made using a Medline(R) database search for the period 1988-1998 on the following key words in various combinations: diagnosis, diagnostic strategy, venous thrombosis, pulmonary embolism, venous thromboembolism. Results of a new study by our group on diagnosis of DVT in hospitalized patients are also discussed. RESULTS: In patients with symptoms or signs suggestive of DVT, compression ultrasound (CUS) appears to be the diagnostic test of first choice, since it is a noninvasive test with high specificity and sensitivity for proximal DVT (about 97%). When CUS gives a negative result it is usually recommended that the test is repeated after one week, since its sensitivity for calf DVT is poor. The positive and negative predictive values (PPV and NPV) of CUS in symptomatic outpatients can be improved if adequate consideration is given to clinical diagnosis, using a standardized model (ref. #9), which allows symptomatic outpatients to be categorized as having a high, moderate or low probability of DVT. In case of agreement between clinical diagnosis and CUS results, no further testing is needed: patients with high or intermediate clinical probability and positive CUS results are treated, while in patients with low clinical probability and negative CUS results the diagnosis of DVT is excluded. In the case of discrepancy between clinical diagnosis and CUS results, D-dimer test and/or venography are requested. However in patients who develop signs or symptoms of DVT in the hospital the clinical model does not work, and diagnosis should be based on an appropriate mix of CUS, D-dimer (DD) test and venography. In patients presenting with signs or symptoms of pulmonary embolism, the ventilation/perfusion (V/P) lung scan remains a pivotal diagnostic test, and pulmonary angiography the reference standard, but both methods have limitations and in recent years other diagnostic tests such as echocardiography, helical (or spiral) computerized tomography, and magnetic resonance imaging have been introduced into clinical practice. Moreover, all four diagnostic tools mentioned for DVT diagnosis can be considered. Several diagnostic strategies have been proposed and evaluated in comparative studies but there is still debate over the most efficient test combination or sequence. INTERPRETATION AND CONCLUSIONS: Diagnostic strategies which include adequate consideration of clinical diagnosis using standardized models have the potential of being more efficient for outpatients (but not for inpatients) with symptoms or signs suggesting DVT of lower limbs. For patients with suspected PE, several diagnostic strategies have been assessed: V/P lung scan remains a pivotal diagnostic test, but its limitations have been increasingly recognized and newer non-invasive techniques are gaining credit. A consensus is still to be reached over the most appropriate combination of diagnostic tests. (+info)