BACKGROUND: The aim of this study was to investigate whether inflammatory markers (interleukin-6 [IL-6] and C-reactive protein [CRP]) in the acute phase of deep vein thrombosis (DVT) are associated with elevated venous outflow resistance (VOR), thrombosis score (TS), reflux and the development of clinical post-thrombotic syndrome (PTS).
METHODS: In 110 patients with a first DVT, plasma concentrations of IL-6 and CRP were determined on the day of admission. VOR, TS and reflux were measured 7 days, 1 and 3 months after diagnosis. After 1 year patients were evaluated for PTS using the Clinical, Etiologic, Anatomic and Pathophysiologic (CEAP) classification and Villalta scale.
RESULTS: Median levels of IL-6 and CRP were 7 pg mL(-1) and 21 mg L(-1), respectively. After 3 months, VOR was elevated in 33 patients (30%), TS in 33 (30%) and reflux in 57 (52%). Incidence of PTS was 36.7% using CEAP>or=3 and 35.4% using Villalta-scale>or=5. Elevated levels of IL-6 and CRP were related to higher outcomes of VOR after 3 months [relative risks (RR) 2.4 (95% CI 1.5-3.9) and 1.4 (1.1-3.3), respectively] and for IL-6 to TS [1.5 (1.1-2.1)]. For reflux no relation was found. After 90 days, elevated outcomes of VOR, TS and reflux were related to PTS after 1 year. The association of IL-6 and CRP with PTS was weak using the CEAP classification with a RR of 1.2 (0.7-2.2) and 1.8 (0.9-3.3) and absent according to the Villalta scale 0.6 (0.2-1.4) and 1.2 (0.6-2.5), respectively.
CONCLUSION: The results of this study suggest that inflammation might play a role in incomplete thrombus clearance, venous outflow obstruction and the development of PTS after 1 year.
UNLABELLED: Post-thrombotic syndrome (PTS) is a well-recognized condition that develops after symptomatic deep venous thrombosis, but the clinical significance and late complications of asymptomatic deep venous thrombosis (ADVT) are unclear.
OBJECTIVE: To determine whether ADVT following minor surgery affects venous function and contributes to the later development of PTS.
PATIENTS/METHODS: The study included 83 patients operated on for Achilles tendon rupture; 38 patients with postoperative ADVT and 45 patients without (control group). The follow-up examinations five years after the operation comprised computerised strain-gauge plethysmography, colour duplex ultrasonography, clinical scoring of venous disease, and quality of life (QOL).
RESULTS: Villalta scores, CEAP classification and QOL did not differ between groups. PTS (=Villalta score > or =5) was found in three ADVT patients (8%) and in two controls (4%). Ultrasonography revealed post-thrombotic changes in 55% of ADVT patients and in none of the controls. Deep venous reflux occurred in 22 ADVT patients and in three controls (P<0.001). There was no difference between groups in plethysmographic variables, demonstrating that the ultrasonographic abnormalities were of negligible haemodynamic significance.
CONCLUSIONS: PTS is not a common sequel to ADVT after minor surgery. Although more than 50% of patients with ADVT developed post-thrombotic changes according to ultrasound, these changes did not result in haemodynamically significant venous dysfunction.
Anticoagulation clinics are increasingly used to manage oral anticoagulant therapy in patients with venous thromboembolic disease (VTE). Such clinics may be in a position to assume greater responsibility for other aspects of the long-term management of VTE, including prevention of post-thrombotic syndrome (PTS). Current guidelines suggest use of graduated elastic compression stockings with a pressure of 30-40 mm Hg at the ankle for 2 years following the diagnosis of deep vein thrombosis (DVT) to prevent PTS. A survey of anticoagulation clinic providers was conducted to determine to what extent patients with DVT are prescribed compression stockings and by whom, and the degree of compression and duration of therapy prescribed. Survey results show a very low rate of use of compression stockings in patients with DVT, and limited adherence to current recommendations for strength and duration of use. We believe that healthcare providers practicing in anticoagulation clinics should be encouraged to expand their scope of practice into a more comprehensive model of antithrombosis care, including prevention of PTS. By doing so, the extent of use of compression stockings might be increased, and adherence to current guidelines for strength and duration of compression might be improved.
O-(bêta-hydroxyéthyl) rutosides (RH) est utilisé pour traiter la maladie veineuse chronique et des signes et symptômes de l'insuffisance veineuse chronique (IVC), les varices, et la maladie veineuse profonde. Cette étude prospective contrôlée indépendante (une étude de registre) évalue dans quelle mesure l'efficacité des ressources humaines au niveau local (région périmalléolaire) peut être augmentée par l'administration d'un gel des ressources humaines d'actualité. L'étude est basée sur l'évaluation des variables microcirculatoires chez les patients souffrant de graves CVI (pression veineuse ambulatoire,> 56 mm Hg) et la microangiopathie veineuse. Les patients sont traités en utilisant 1 des 3 suivants: régimes de traitement par voie orale avec des sachets de 1 g de RH (2 g / j au total) ainsi que d'actualité RH gel 2% appliquée 3 fois par jour à la région interne périmalléolaire; traitement par voie orale seulement (même posologie), ou de lumière bas de contention élastiques. Laser Doppler du flux peau au repos, le flux peau à la région périmalléolaire, et PO2 transcutanée et PCO2 sont mesurés au début et à la fin de la période de traitement. Un groupe comparable de personnes en bonne santé sans traitement est observée pendant 8 semaines. Dans les groupes de traitement, le flux est augmenté, PO2 est diminué, et de la PCO2 est augmenté par rapport à la peau normale. A 4 et 8 semaines, l'amélioration du flux peau (qui est diminuée par toutes les mesures), l'augmentation de la PO2, et la diminution de la PCO2 (qui indique une amélioration de la microcirculation) sont statistiquement significativement supérieure dans le groupe de traitement par voie orale et topique combiné (P < .05). Pas d'effets indésirables, des problèmes de tolérance ou des problèmes de conformité sont constatés. Ces résultats indiquent un rôle important des ressources humaines dans le traitement et le contrôle de l'ICB et la microangiopathie veineuse.
Journal»Journal of vascular surgery : official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
OBJECTIF: bas de contention sont largement appliquées après aiguë thrombose veineuse profonde proximale, mais leur efficacité dans la prévention le syndrome post-thrombotique reste controversée. Cette étude a évalué l'effet de la thérapie de compression prolongée après un traitement standard de 6 mois après une thrombose veineuse profonde aiguë. MÉTHODES: De 900 patients dépistés, nous répartis aléatoirement 169 patients avec une première thrombose ou récurrente veineuse profonde proximale après avoir reçu 6 mois de traitement standard de porter des bas de compression ou non. Analyse de l'efficacité primaire a été réalisée sur le point de fin de modifications de la peau émergents (C4-C6 selon la classification CEAP). Une analyse secondaire a été fait sur les symptômes associés à un syndrome post-thrombotique. Toutes les analyses ont été effectuées selon l'intention de traiter principe. RÉSULTATS: Le point final primaire survenus chez 11 patients (13,1%) dans le groupe de traitement comparativement à 17 (20,0%) dans le groupe contrôle (hazard ratio [HR], 0,60, intervalle de confiance 95% [IC], 0.28 à 1.28; P = .19). Moyenne de suivi était de 3,2 ans et 2,9 ans, respectivement. Cinq autres patients dans le groupe de contrôle requis en raison d'une thérapie de compression post-thrombotiques signes et les symptômes ne figurent pas dans le critère primaire. Pas d'ulcération veineuse a été observée dans les deux groupes. Dans les analyses de sous-groupes du point de fin primaire, nous avons observé une grande sexe différence spécifique entre les femmes (HR, 0,11; IC à 95%, de 0,02 à 0,91) et les hommes (HR: 1,07; IC à 95%, 0,42 à 2,73). Le soulagement des symptômes était significative en faveur du traitement de compression lors de la première année, mais pas par la suite. CONCLUSION: la thérapie par compression prolongée après une thrombose veineuse profonde proximale réduit significativement les symptômes et peuvent empêcher les modifications de la peau post-thrombotiques. Que ces résultats se traduisent à la prévention des états avancés de la maladie avec des ulcérations reste incertaine.
BACKGROUND: The reason some patients with deep venous thrombosis (DVT) develop the postthrombotic syndrome is not well understood.
OBJECTIVE: To determine the frequency, time course, and predictors of the postthrombotic syndrome after acute DVT.
DESIGN: Prospective, multicenter cohort study.
SETTING: 8 Canadian hospital centers.
PATIENTS: 387 outpatients and inpatients who received an objective diagnosis of acute symptomatic DVT were recruited from 2001 to 2004.
MEASUREMENTS: Standardized assessments for the postthrombotic syndrome using the Villalta scale at 1, 4, 8, 12, and 24 months after enrollment. Mean postthrombotic score and severity category at each interval was calculated. Predictors of postthrombotic score profiles over time since diagnosis of DVT were identified by using linear mixed modeling.
RESULTS: At all study intervals, about 30% of patients had mild (score, 5 to 9), 10% had moderate (score, 10 to 14), and 3% had severe (score >14 or ulcer) postthrombotic syndrome. Greater postthrombotic severity category at the 1-month visit strongly predicted higher mean postthrombotic scores throughout 24 months of follow-up (1.97, 5.03, and 7.00 increase in Villalta score for mild, moderate, and severe 1-month severity categories, respectively, vs. none; P < 0.001). Additional predictors of higher scores over time were venous thrombosis of the common femoral or iliac vein (2.23 increase in score vs. distal [calf] venous thrombosis; P < 0.001), higher body mass index (0.14 increase in score per kg/m(2); P < 0.001), previous ipsilateral venous thrombosis (1.78 increase in score; P = 0.001), older age (0.30 increase in score per 10-year age increase; P = 0.011), and female sex (0.79 increase in score; P = 0.020).
LIMITATIONS: Decisions to prescribe compression stockings were left to treating physicians rather than by protocol. Because international normalized ratio data were unavailable, the relationship between anticoagulation quality and Villalta scores could not be assessed.
CONCLUSION: The postthrombotic syndrome occurs frequently after DVT. Patients with extensive DVT and those with more severe postthrombotic manifestations 1 month after DVT have poorer long-term outcomes.
BACKGROUND/OBJECTIVES: We prospectively measured change in quality of life (QOL) during the 2 years after a diagnosis of deep vein thrombosis (DVT) and evaluated determinants of QOL, including development of the post-thrombotic syndrome (PTS).
PATIENTS/METHODS: Consecutive patients with acute DVT were recruited from 2001 to 2004 at eight hospitals in Canada. At study visits at baseline, and 1, 4, 8, 12 and 24 months, clinical data were collected, standardized PTS assessments were performed, and QOL questionnaires were self-completed. Generic QOL was measured using the Short-Form Health Survey-36 (SF-36) questionnaire. Venous disease-specific QOL was measured using the Venous Insufficiency Epidemiological and Economic Study (VEINES)-QOL/Sym questionnaire. The change in QOL scores over a 2-year follow-up was assessed. The influence of PTS and other characteristics on QOL at 2 years was evaluated using multivariable regression analyses.
RESULTS: Among the 387 patients recruited, the average age was 56 years, two-thirds were outpatients, and 60% had proximal DVT. The cumulative incidence of PTS was 47%. On average, QOL scores improved during follow-up. However, patients who developed PTS had lower scores at all visits and significantly less improvement in QOL over time (P-values for PTS*time interaction were 0.001, 0.012, 0.014 and 0.006 for PCS, MCS, VEINES-QOL and VEINES-Sym). Multivariable regression analyses showed that PTS (P < 0.0001), age (P = 0.0009), proximal DVT (P = 0.01) and inpatient status (P = 0.04) independently predicted 2-year SF-36 PCS scores. PTS alone independently predicted 2-year VEINES-QOL (P < 0.0001) and VEINES-Sym (P < 0.0001) scores.
CONCLUSIONS: Development of PTS is the principal determinant of health-related QOL 2 years after DVT. Our study provides prognostic information on patient-reported outcomes after DVT and emphasizes the need for effective prevention and treatment of the PTS.
PURPOSE: A study was conducted to evaluate compliance with the Sixth American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy guidelines for the prevention of venous thromboembolism (VTE) in hospitals.
METHODS: Using the HealthFacts database, hospitalized patients, age 40 years or more, with medical conditions at risk for VTE (surgical, trauma, and acute spinal injury patients) were identified. Hospital admissions on or after January 1, 2001, and concluded by March 31, 2005, were included if they met any of the following conditions as defined in the ACCP Consensus Conference on Antithrombotic Therapy guidelines: patients at risk of VTE medical conditions, major orthopedic surgery, general surgery, gynecological surgery, urologic surgery, trauma, neurosurgery, and acute spinal cord injury. Hospitalizations were identified using the International Classification of Diseases, 9th Revision, Clinical Modification codes. The primary objective was to examine whether patients received one of the indicated anticoagulants at the proper dosage and during the relevant hospital days as determined in the ACCP guidelines. Rates of compliance were assessed, and the reasons for guideline noncompliance were also determined.
RESULTS: The overall compliance rate with ACCP guidelines was 13.3% (ranging from 2.8% for neurosurgery to 52.4% for orthopedic surgery) in the 123,304 hospital admissions that were reviewed. Only 15.3% of patients with at-risk medical conditions received prophylaxis in accordance with ACCP guidelines. Potential reasons for guideline noncompliance among selected conditions included the omission of prophylaxis, inadequate prophylaxis duration, and the wrong type of anticoagulant.
CONCLUSION: A retrospective study found low rates of compliance with guidelines for thromboprophylaxis.
Elastic compression stockings are useful for preventing post-thrombotic syndrome after deep venous thrombosis (DVT). Less is known about their effects on thrombus recanalization and the optimal timing for starting compression. This study investigated whether compression applied early was more effective than when started 2 weeks after DVT. Seventy-three patients with DVT were randomly assigned to elastic compression hosiery starting either immediately after diagnosis or 2 weeks later. After 14 and 90 days the residual thrombus was measured by compression ultrasonography, and venous patency and any pathological reflux were recorded. There were significantly more recanalized venous segments in the group treated with early compression. Recanalization of popliteal DVT veins, expressed as the reduction of vein diameter, was also better in the early compression group than controls (day 14, 6.5 +/- 3 versus 5 +/- 2 mm, P = 0.035; day 90, 3.7 +/- 3 versus 2.1 +/- 1.7 mm; P = 0.014). On day 14 the mean score for popliteal patency was significantly better for the early compression patients (1.0 +/- 0.6 versus 1.5 +/- 0.5, P = 0.0015). In conclusion, elastic compression applied immediately at diagnosis of DVT was safe and effective on the surrogate end-points investigated in this study. Longer follow-up in larger series is needed to verify the patterns of recurrence of DVT and post-thrombotic syndrome.
CONTEXTE: Message thrombotique du syndrome (PTS) est une complication lourde et coûteuse de la thrombose veineuse profonde (TVP) qui se développe dans 20-40% des patients dans les 1-2 ans après une TVP symptomatique. Les patients atteints de douleur chronique aux jambes et le gonflement et peuvent développer des ulcères. Valvules veineuses des thrombus lui-même ou thrombus-médiateurs de l'inflammation associés est considéré comme un événement clé d'initiation pour le développement de l'hypertension veineuse qui, souvent, sous-tend PTS. Comme les traitements existants pour PTS sont extrêmement limitées, des stratégies qui mettent l'accent sur la prévention du développement de la PTS chez les patients souffrant de TVP sont plus susceptibles d'être efficace et rentable dans la réduction de son fardeau. Bas de contention élastique (ECS) pourrait être utile dans la prévention de PTS; toutefois, les données sur leur efficacité sont rares et contradictoires. MÉTHODES / CONCEPTION: Le procès SOX est une étude randomisée, assignation secrète, en double aveugle multicentrique essai clinique. L'objectif de l'étude est d'évaluer ECS pour éviter PTS. Un total de 800 patients présentant une TVP proximale seront randomisés à l'un des 2 groupes de traitement: ECS ou un placebo (inactif) bas portés sur la jambe touchée DVT-par jour pendant 2 ans. Le résultat principal est l 'incidence de la PTS au cours du suivi. Les résultats secondaires sont la gravité de la PTS, la thromboembolie veineuse (TEV) récidive, la mort de TEV, la qualité de vie et de rapport coût-efficacité. Les résultats seront évalués au cours de 6 visites à la clinique et 2 suivis téléphoniques. Au départ, 1 et 6 mois, des échantillons de sang seront obtenus pour évaluer le rôle de médiateurs inflammatoires et des marqueurs génétiques de thrombophilie dans le développement de PTS (Bio-SOX sous-étude). DISCUSSION: Le procès SOX sera la plus grande étude et le premier avec un contrôle placebo pour évaluer l'efficacité d'ECS pour éviter PTS. Il est conçu pour fournir des données définitives sur les effets de ECS sur la fréquence et la gravité de la PTS, ainsi que de récurrence de TVP, rapport coût-efficacité et la qualité de la vie. Cette étude permettra également d'évaluer prospectivement le rôle prédictif de biomarqueurs qui reflètent putatifs mécanismes physiopathologiques sous-jacents dans le développement de cliniques PTS. En tant que tel, nos résultats auront une incidence directe sur la prise en charge des patients atteints de thrombose veineuse profonde. Enregistrement des essais: NCT00143598 et ISRCTN71334751.
The aim of this study was to investigate whether inflammatory markers (interleukin-6 [IL-6] and C-reactive protein [CRP]) in the acute phase of deep vein thrombosis (DVT) are associated with elevated venous outflow resistance (VOR), thrombosis score (TS), reflux and the development of clinical post-thrombotic syndrome (PTS).
METHODS:
In 110 patients with a first DVT, plasma concentrations of IL-6 and CRP were determined on the day of admission. VOR, TS and reflux were measured 7 days, 1 and 3 months after diagnosis. After 1 year patients were evaluated for PTS using the Clinical, Etiologic, Anatomic and Pathophysiologic (CEAP) classification and Villalta scale.
RESULTS:
Median levels of IL-6 and CRP were 7 pg mL(-1) and 21 mg L(-1), respectively. After 3 months, VOR was elevated in 33 patients (30%), TS in 33 (30%) and reflux in 57 (52%). Incidence of PTS was 36.7% using CEAP>or=3 and 35.4% using Villalta-scale>or=5. Elevated levels of IL-6 and CRP were related to higher outcomes of VOR after 3 months [relative risks (RR) 2.4 (95% CI 1.5-3.9) and 1.4 (1.1-3.3), respectively] and for IL-6 to TS [1.5 (1.1-2.1)]. For reflux no relation was found. After 90 days, elevated outcomes of VOR, TS and reflux were related to PTS after 1 year. The association of IL-6 and CRP with PTS was weak using the CEAP classification with a RR of 1.2 (0.7-2.2) and 1.8 (0.9-3.3) and absent according to the Villalta scale 0.6 (0.2-1.4) and 1.2 (0.6-2.5), respectively.
CONCLUSION:
The results of this study suggest that inflammation might play a role in incomplete thrombus clearance, venous outflow obstruction and the development of PTS after 1 year.
