BACKGROUND: Half of all lower limb deep vein thromboses (DVT) are distal DVT that are equally distributed between muscular calf vein thromboses (MCVT) and deep calf vein thromboses (DCVT). Despite their high prevalence, MCVT and DCVT have never been compared so far, which prevents possible modulation of distal DVT management according to the kind of distal DVT (MCVT or DCVT).
METHODS: Using data from the French, multicenter, prospective observational OPTimisation de l'Interrogatoire dans l'évaluation du risque throMbo-Embolique Veineux (OPTIMEV) study, we compared the clinical presentation and risk factors of 268 symptomatic isolated DCVT and 457 symptomatic isolated MCVT and the 3-month outcomes of the 222 DCVT and 390 MCVT that were followed-up.
RESULTS: During the entire follow-up, 86.5% of DCVT patients and 76.7% of MCVT patients were treated with anticoagulant drugs (P = .003). MCVT was significantly more associated with localized pain than DCVT (30.4% vs 22.4%, P = .02) and less associated with swelling (47.9% vs 62.7%, P < .001). MCVT and DCVT patients exhibited the same risk factors profile, except that recent surgery was slightly more associated with DCVT (odds ratio, 1.70%; confidence interval, 1.06-2.75), and had equivalent comorbidities as evaluated by the Charlson index. At 3 months, no statistically significant difference was noted between MCVT and DCVT in death (3.8% vs 4.1%), venous thromboembolism recurrence (1.5% vs 1.4%), and major bleeding (0% vs 0.5%).
CONCLUSION: Isolated symptomatic MCVT and DCVT exhibit different clinical symptoms at presentation but affect the same patient population. Under anticoagulant treatment and in the short-term, isolated distal DVT constitutes a homogeneous entity. Therapeutic trials are needed to determine a consensual mode of care of MCVT and DCVT.
BACKGROUND: Treatment of isolated calf muscle vein thrombosis (ICMVT) is controversial. There are no data from prospective, controlled studies. Objective of this article was to compare the efficacy and safety of a short-term course of anticoagulation with compression therapy alone.
METHODS: We prospectively randomized patients with symptomatic, sonographically proven ICMVT in the soleal and/or gastrocnemial muscle veins in two treatment arms. The first received low-molecular-weight heparin for 10 days at therapeutic dosage (nadroparin 180 anti-activated factor X units once daily) and compression therapy for three months, and the second received compression therapy alone. Primary efficacy endpoint of the study was sonographically proven progression of ICMVT into the deep veins and clinical pulmonary embolism (PE) as confirmed by objective testing. Secondary efficacy and primary safety endpoints were major bleeding, death not due to PE, and complete sonographically proven recanalization of the muscle vein. We assessed transient and permanent risk factors for venous thromboembolism.
RESULTS: One-hundred seven patients were finally ruled eligible for evaluation: 89% outpatients, 11% hospitalized patients. In the heparin group (n=54) progression to deep vein thrombosis (DVT) occurred in two patients (3.7%), in the group compression therapy alone (n=53) progression to DVT occurred in two patients (n.s.). No clinical PE and no death occurred. Thrombus recanalization after 3 months was not statistically significant different between the two study groups. No major bleeding occurred.
CONCLUSION: The data do not show superiority of a short-term regimen of low-molecular-weight heparin and compression therapy in comparison with compression therapy alone in patients with ICMVT in a rather low-risk population.
The natural history of calf deep-vein thrombosis (DVT) is still uncertain and it is debated whether it warrants to be diagnosed and treated. We aimed to investigate the complication rate of untreated isolated calf DVT (ICDVT). Symptomatic outpatients were prospectively managed with serial compression ultrasonography (SCUS). Those without proximal DVT and with likely pre-test clinical probability (PCP) or altered D-dimer received immediate subsequent complete examination of calf deep veins (CCUS) by a different operator. The result of CCUS was kept blind both to the managing doctor and the patient and disclosed after three months. Primary outcome was the rate of venous thromboembolism at three months. We examined 431 subjects (196 males; median age 68.0 years) in whom five outcomes were recorded (1.2%; 95% confidence intervals [CI]: 0.4-2.7). If CCUS results had been available, outcomes would have been recorded in 3/424 patients (0.7%; 95% CI: 0.2-2.1) with two events in subjects negative at both serial and complete CUS. ICDVT was diagnosed in 65 subjects (15.3%; 95% CI: 12-19); of whom 59 remained uneventful (one was lost to follow-up). A significant higher rate of outcomes was recorded in subjects with than without ICDVT (5/64; 7.8%; 95% CI: 3-17 vs. 3/351; 0.8%; 95% CI: 0-2; p=0.003). However, after excluding two events picked at serial CUS in subjects with ICDVT, the difference became barely significant (3/64; 4.7%; 95% CI: 1-13; p=0.049). Thrombotic evolution of untreated ICDVT in high-risk subjects may be relevant. Larger studies are needed to address this issue.
AIM: The optimal treatment of isolated distal deep vein thrombosis (ID-DVT) is still controversial. A complete anticoagulation as soon as the diagnosis is made is recommended by some authors. Alternatively, other authors suggest to perform serial ultrasonography assessments to detect the possible extension of DVT towards proximal veins. Only in this case the treatment should be initiated. Furthermore, the optimal duration of treatment is far from established. The Treatment of Isolated Calf Thrombosis (TICT) study was set up to assess the efficacy and safety of a particular treatment regimen of ID-DVT based on low molecular weight heparins (LMWH).
METHODS: The drug treatment consisted of a twice-daily subcutaneous administration of a full dose of weight-adjusted LMWH for one week, followed by a half dose of LMWH administered once-daily for another three weeks. At the end of the four-week period of treatment, a colour-coded Doppler ultrasonography (CCDU) assessment was scheduled and after three months a follow-up visit was performed. If a patient was unable to attend the visit, he was contacted by a phone-call to assess if any adverse events occurred. The study enrolled 192 outpatients with ID-DVT confirmed by CCDU. Twenty-one out of 192 patients (10.9%) were excluded for violation of protocol. Thus 171 (39.9% men, mean age of 60.45 years ) were eligible and were included in the study. Sixty-one patients (36.6%) presented an unprovoked ID-DVT.
RESULTS: Events during the period of treatment (4 weeks). Ten out of 171 patients (5.8%) had complications: five patients showed an extension proximal to the knee (2.9%) all with an unprovoked ID-DVT; two showed an extension of thrombus within the distal veins. Three patients (1.7%) suffered from minor bleeding; there was no major bleeding. Further events during three months of observation occurred. Five patients had thrombus recurrences: four patients showed a proximal DVT (3 with a previous unprovoked ID-DVT, 1 with a previous ID-DVT secondary to a traumatic leg fracture, with persistent difficulty of deambulation); one, with a previous secondary thrombosis, showed a ID-DVT.
CONCLUSIONS: In our study only 2.9% of patients with ID-DVT showed a progression of thrombosis to proximal deep veins; the majority of thrombus progression, during the treatment period, was observed in patients with unprovoked ID-DVT. Our results support the usefulness of a prolonged treatment in unprovoked ID-DVT.
BACKGROUND: Although muscular calf vein thrombosis (MCVT) is commonly seen in everyday practice, no treatment guidelines are available. This study evaluated short-term and mid-term outcome of isolated symptomatic MCVT.
METHOD: We included prospectively and consecutively all patients referred to an outpatient clinic with isolated MCVT. Clinical signs were pain or edema, or both, of the calf. Diagnosis was established with duplex ultrasound (DUS) examination. Not completely occlusive and asymptomatic MCVTs were excluded. Patients were followed up clinically and with DUS at 1, 3, and 9 months, and up to 36 months. Anticoagulant therapy at curative dosage associated with compression was prescribed for 1 month and was extended for 2 additional months in case of incomplete recanalization at 1 month or if risk factors for venous thromboembolism (VTE) were present.
RESULTS: Included were 128 patients (78 women, 50 men) presenting with 131 MCVTs. Their mean age was 57.02 +/- 15.36 years (range, 20 to 87 years). Thrombus was present in the soleal veins (SoV) in 73 patients (55.7%) and in the medial gastrocnemius veins (MGV) in 58 (44.3%). Initial symptoms were isolated pain in the calf in 90 patients, isolated edema of the calf in six, and pain plus edema in 32. Anticoagulant therapy was prescribed in 53 patients (41.4%) for 1 month, in 59 (46.1%) for 3 months, and in 13 (10.2%) for >or=6 months. At baseline, nine pulmonary embolisms (7%), complicated with MCVT, were observed in six MGV patients (10.3%) and three SoV patients (4.1%; P = .18). Two nonfatal hemorrhagic events occurred. Three patients died during the follow-up after anticoagulant therapy had been discontinued. Recanalization of MCVT was considered complete at 1, 3, and 9 months in 54.8%, 84.7%, and 96% of cases, respectively, with no significant difference between the MGV and the SoV groups. Twenty-nine VTE symptomatic recurrences (PE, n = 6; DVT including MCVT, n = 23) were observed in 24 patients (18.8%), with similar figures in both thrombosis groups: none at 3 months, 11 between 3 and 9 months and 18 between 9 and 36 months. No extension of the MCVT or a recurrence of VTE was observed in patients treated with anticoagulant therapy. Twelve cases of superficial thrombophlebitis occurred during the follow-up period.
CONCLUSION: This study confirms the place of MCVT in VTE disorders. Pulmonary embolism at the MCVT initial diagnosis was not rare, and mid-term follow-up (mean, 26.7 months) revealed that 18.8% of patients had at least one VTE recurrence. The treatment of acute MCVT needs to be standardized because no guidelines currently exist.
BACKGROUND: The definition of gastrocneumus and soleus deep-vein thrombosis (DVT) remains controversial. The purpose of this study was to evaluate the clinical significance of muscular deep-vein thrombosis after total knee arthroplasty (TKA).
METHODS: This study consisted of 359 consecutive patients undergoing TKA evaluated for DVT by ascending venography. Venographies were performed 5 to 7 days after surgery. Those patients showing positive DVT underwent a follow-up venographic study at 3 months. The evaluation parameters included clinical symptoms, late DVT, thrombus propagation and pulmonary embolism. The data from patients with isolated muscular DVT were compared statistically with those patients with DVT of the leg veins and combined DVT.
RESULTS: Of 359 patients, 175 (49%) developed venographic DVT including 160 with distal and 15 with proximal DVT. Of the 160 cases with distal DVT, 83 (52%) involved the gastroneumus and soleus muscular veins. Of these 83 cases, 38 (46%) were isolated muscular DVT and 45 (54%) involved muscular branches and major leg veins including the anterior and posterior tibial and peroneal veins. Patients with isolated muscular DVT showed comparable rates of clinical symptoms, late DVT, thrombus propagation and no pulmonary embolism compared with patients with DVT in the major leg veins (p = 0.874, 0.398 and 1.000) and patients with combined DVT (p = 0.155, 0.592 and 1.000).
CONCLUSION: The clinical significance of isolated muscular DVT is comparable to that of the major leg veins and combined DVT. Muscular DVT in the calf is considered a significant clinical entity and should be treated accordingly.
The aim of this study was to evaluate different durations of treatment in patients with calf venous thrombosis (CVT) involving 1 or more deep veins. The authors studied 2 groups of patients with postsurgical CVT diagnosed by echo-color Doppler. The first group consisted of 68 patients with CVT involving a single vein, and the second group consisted of 124 patients with CVT involving 2 or more veins. Immediately after diagnosis, all patients were treated with nadroparin calcium and sodium warfarin. Heparin treatment was withdrawn after 5-6 days of treatment, when the international normalized ratio (INR) was stabilized between 2 and 3. Each group was divided into 2 subgroups receiving anticoagulation treatment for 6 or 12 weeks, respectively. The endpoint was proximal extension of the thrombotic lesion, defined as the extension of the thrombus to the popliteal and/or femoral vein. In patients with single-vessel CVT there was no significant difference between the 2 subgroups, whereas in patients with CVT involving 2 or more vessels, a statistically significant difference was observed, the number of cases showing proximal extension of the thrombus being higher among patients treated for 6 weeks. Twelve weeks of anticoagulation treatment is better than 6 weeks only in patients with postsurgical CVT involving 2 or more veins.
Les résultats cliniques des patients diagnostiqués avec la maladie thromboembolique veineuse (VTED) ont rarement été évalués sur de grandes séries de patients des institutions individuelles. Ce fut un travail basé sur notre pratique de dépistage systématique de tous les embolies présumé pulmonaire (EP) et la thrombose veineuse profonde (TVP) des patients avec veineuse proximale et distale bilatérale des États-Unis a été conçu pour évaluer la survie, la récidive et la survenue du cancer chez les patients diagnostiqués avec une TVP symptomatique ou asymptomatique et d'évaluer leur relation avec le site de la thrombose veineuse profonde (proximale vs distale, bilatérale vs unilatérale). Notre étude est basée sur le recoupement du registre VTED du CHU de Grenoble auprès du Registre du cancer local et les données de mortalité de la communauté. Les analyses de survie ont été réalisées avec la méthode de Kaplan-Meier; variables pronostiques ont été testés en utilisant le test du log-rank. Un total de 1913 patients présentant une thrombose veineuse profonde des membres inférieurs à partir de 1993 à 1998 ont été inclus (57 femmes%, âge moyen 69 ans). Parmi ceux-ci, 1018 patients ont été diagnostiqués avec une TVP proximale (156 bilatérale) et 895 TVP distale (112 bilatérale). PE a été associé à 760 patients. Les patients atteints de PE et aucune TVP détectée n'ont pas été inclus. A 2 ans, les taux de survie ajustés étaient de 80% chez les patients atteints unilatérale-distale TVP, 67% en bilatérale-distale, de 72% unilatérale-proximale et 65% chez les patients TVP proximales bilatérale-. Les taux cumulés de récidive VTED étaient de 7,7% en unilatérale-distale TVP, 13,3% lorsque la TVP était bilatérale-distale, de 14% lorsque unilatérale-proximale et 13,2% lorsque bilatérale proximale. Le taux de nouveaux cas de cancer était de 6,4% en unilatérale-distale TVP, 10,8% quand elle était bilatérale-distale, 6,5% lorsque unilatérale-proximale et 6,1% en bilatérale proximale. Basé sur une large série de patients non sélectionnés, nos résultats montrent que le site de la thrombose veineuse profonde et principalement de la bilatéralité fournit d'importantes informations pronostiques qui peuvent être utilisés dans la mise en place de stratégies médicales.
OBJECTIVE: Venous disease was evaluated in relation to post-thrombotic syndrome 5 years after deep venous thrombosis (DVT) in patients treated with a regimen of low-molecular-weight heparin (LMWH) and warfarin in a Hospital-in-the-Home program.
METHODS: The presence of flow, reflux and compressibility in 51 patients (102 limbs, 54 with DVT and 48 without DVT) was assessed by duplex ultrasound scanning. Blood tests were carried out for prothrombotic screening. Venous disease was related to pathologic severity of post-thrombotic syndrome, characterized by the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification on a scale of 0 to 6.
RESULTS: In the 102 limbs studied, 30 patients (59%) had an underlying thrombophilic disorder. The most common cause of DVT was postoperation and prolonged immobilization not related to postoperation. The most common thrombophilic abnormalities were anticardiolipin antibody and a deficiency of protein C or S, or both. Twenty-six limbs (48%) had proximal involvement (proximal and proximal plus distal DVT); resolution (recanalization or normal vein) in these limbs was seen in 85% at 6 months and 96% at 5 years. After 5 years, 25 of these proximal DVT limbs (96%) developed reflux and there were 4 limbs in CEAP class 0, 8 in classes 1 to 3, and 14 in classes 4 to 6. All of the 28 limbs (52%) with distal DVT showed DVT resolution by 6 months. After 5 years, 10 limbs (36%) developed reflux, and 13 limbs were in class 0, 12 in classes 1 to 3, and 3 limbs in classes 4 to 6. No DVT was detected in the 48 contralateral limbs, but reflux was detected in 25 limbs (52%), predominately in the superficial veins (16 limbs, 64%).
CONCLUSIONS: The resolution of thrombus was more rapid and complete in patients with distal DVT than in those with proximal DVT. Patients with proximal DVT developed a more severe form of post-thrombotic syndrome that was likely related to the development of deep venous reflux. An important finding of this study was an unexpectedly high incidence of venous reflux in the apparently unaffected limb. Although these non-DVT limbs were not investigated at presentation, our data is consistent with the hypothesis that DVT may result in a more systemic disorder of venous function.
Background: Postoperative asymptomatic deep venous thromboses (ADVT) can give rise to posttthrombotic syndrome (PTS), but there are still many unresolved issues in this context. For example, there is a lack of knowledge regarding the fate of small ADVT following minor orthopedic surgery. This follow-up study evaluates postthrombotic changes and clinical manifestations of PTS in a group of patients with asymptomatic calf vein DVT after surgery for Achilles tendon rupture.Methods: Forty-six consecutive patients with distal ADVT were contacted and enrolled in a follow-up consisting of a single visit at the hospital at a mean time of 5 years postoperatively, including clinical examination and scoring, ultrasonography and venous plethysmography. All patients had participated in DVT-screening with colour duplex ultrasound (CDU) 3 and 6 weeks postoperatively and 80% of them were treated with anticoagulation.Results: With CDU postthrombotic changes and deep venous reflux were detected at follow-up in more than 50% of the patients, more commonly in somewhat larger calf
DVT:
s initially affecting more than one vessel. However, only about 10% of the patients had significant venous reflux according to venous plethysmography. No patient had plethysmographic evidence of remaining outflow obstruction, but presence of postthrombotic changes shown with CDU negatively influenced venous outflow capacity measured with plethysmography. A clinical entity of PTS was rarely found and occurred only in two patients (4%) and then classified by Villalta scoring as of mild degree with few clinical signs of disease. Distal
ADVT:
s detected in the early postoperative period (3 weeks) showed DVT-progression in 75% of the limbs that were still immobilized and without anticoagulation.Conclusions: Asymptomatic postoperative distal
DVT:
s following surgery for Achilles tendon rupture have a good prognosis and a favourable clinical outcome. In our material of 46 patients the general appearance of the clinical entity of PTS at 5 years follow-up was low (<5%). Morphological and functional abnormalities were mainly seen in those patients that initially had somewhat larger distal
