THROMBOEMBOLISM – Part 3
Moderators: BO EKLÖF (Sweden), SHUNICHI HOSHINO (Japan)
Safety and effectiveness of combined regional thrombolysis
and thrombectomy in acute lower- limb thrombosis
W. BLÄTTLER (Switzerland)
The gold standard for treatment of deep vein thrombosis is unknown. Conservative management of heparin therapy shows postthrombotic syndrome in 49.1% after 24 months.1
Heparin and compression therapy was able to reduce the frequency of postthrombotic sequelae to 20%.2 Systemic thrombolysis gives a high rate of patent, recanalized vessels, but has a higher bleeding rate. Thrombectomy removes the thrombus but leads to valve damage and has an unacceptably high mortality rate. In this report, regional thrombolysis was achieved by infusing Urokinase into a dorsal foot vein after previously excluding the extremity from the circulation by a thigh cuff inflated to 300 mm Hg. The proximal veins were cleared by surgical thrombectomy with a Fogarty catheter through an inguinal venotomy. After clamping the external iliac artery, the thigh block was opened, and the thrombi flushed out by the reactive hyperemia. Blood was retrieved, washed, and retransfused. Twenty-one patients with a mean age of 25 years were treated and the maximum follow up time was 8 years in 14 patients. All patients had proximal venous thrombosis with 17 extending to the iliac region. Complications were found in 33% and 5 patients (23.8%) were reoperated on due to hematomas. There were no PE found. After 1 year 16 out of 20 patients had complete restitution, 2 had symptoms of venous claudication, and 2 showed signs of PTS. After 8 years 13/14 patients were free of PTS (93%). In conclusion one can say that in this selected group of young patients this combined approach seems feasible, restoring vein valve function in a high number of patients.
1.Prandoni P et al. Pathophysiol Haemost Thromb. 2002; 132(suppl 2)Abst.036.
2. Brandjes DP et al. Lancet. 1997;349:759-762.
Exclusion of deep vein thrombosis by measuring spot skin
temperatures using a hand-held thermocomparitor
S. ENOCH (UK)
The author presented preliminary results on a novel screening tool for DVT. This instrument works on the basis of thermography but is small and portable, and could therefore be used in primary care institutions. Thirty-three patients with suspected DVT were investigated by this method and duplex scanning. The 10 patients with actual DVT were correctly identified, and the rate of false positive results was 50%.
This new tool seems to have a high sensitivity, but a low specificity in detecting DVT, the same as thermography. Larger studies comparing it with other screening tools such as D-dimer tests will be performed.
Incidence of deep vein thrombosis after varicose
A. M. VAN RIJ (New Zealand)
Varicose vein surgery is often considered to be minor surgery with little risk of postoperative DVT. This is a prospective trial in 377 consecutive patients addressing this question.
Duplex scanning was performed preoperatively and 2 and 4 weeks postoperatively, and at 6 months, 1, and 3 years. The decision to give LMWH prophylaxis was left to the operating doctors. In most cases this was one or two doses of LMWH. The mean age of patients was 53 years (21 to 83 years). DVT was detected in 20 cases (5.3%), 2.1 were symptomatic. Ninety percent of DVT were restricted to calf veins; 10% were found in the popliteal vein. A positive family history for DVT, age and stage of CVI were positive predictors for DVT. There was no difference in outcome if LMWH prophylaxis was given.
In conclusion it was stated that the incidence of DVT was relatively low. LMWH prophylaxis is not suggested in patients <40 years. In at-risk patients prophylaxis should be given, but a longer period of treatment should be considered.