Clinical, laboratory and anatomopathological study of caudal vena cava thrombosis in cattle / Estudo clínico, laboratorial e anatomopatológico da trombose da veia cava caudal em bovinos

This paper aimed to describe the main clinico-epidemiological, laboratory, and anatomopathological findings in 10 cattle affected with caudal vena cava thrombosis. The main clinical signs observed were decreased milk production, reduced appetite, apathy, impairment of ruminal motility, cardiorespiratory disorders (tachycardia and tachypnea), epistaxis, hemoptysis, and ascites. Intercurrent diseases such as mastitis, metritis, and phlebitis were verified. The hematological findings were mild anemia, leukocytosis due to neutrophilia with regenerative left shift, and hyperfibrinogenemia. The pathological exams revealed thrombi in the caudal vena cava, hepatomegaly, ascites, liver abscesses, pulmonary edema and emphysema, and abscesses in the lungs. The association of epidemiological information, clinical signs such as respiratory distress, epistaxis or hemoptysis, in addition to anemia and leukocytosis due to neutrophilia, as well as the occurrence of thrombus in the caudal vena cava as pathological findings, are indicative elements of the clinical picture of vena cava thrombosis in cattle. It is reiterated that this disease has an unfavorable prognosis and, when diagnosed, the animal must be culled.(AU)

Este trabalho teve por objetivo descrever os principais achados clínico-epidemiológicos, laboratoriais e anatomopatológicos de 10 bovinos diagnosticados com trombose da veia cava caudal. Os principais achados clínicos foram redução da produção leiteira, diminuição do apetite, apatia, comprometimento da dinâmica ruminal, alterações cardio-respiratórias (taquicardia e taquipnéia), epistaxe, hemoptise e ascite. Foi constatada a ocorrência de doenças intercorrentes como mastite, metrite e flebite. O hemograma revelou discreta anemia, leucocitose por neutrofilia com desvio para esquerda regenerativo e hiperfibrinogenemia. No exame anatomopatológico revelou trombos localizados na veia cava caudal, hepatomegalia, ascite e abscessos hepáticos; além de abscessos, enfisema e edema pulmonares. A associação de informações epidemiológicas, sinais clínicos como desconforto respiratório, epistaxe ou hemoptise, além de anemia e leucocitose por neutrofilia, bem como a ocorrência de trombo na veia cava caudal como achados patológicos são elementos indicativos do quadro clínico de trombose de veia cava em bovinos. Reitera-se que essa doença tem prognóstico desfavorável e, quando diagnosticada, o animal deve ser abatido.(AU)

Dímero D: su importancia en el tromboembolismo venoso / D-Dimer: Its importance in venous thromboembolism

El tromboembolismo venoso es una condición frecuente en la práctica clínica. La determinación del Dímero D ha sido utilizada como prueba para el diagnóstico del tromboembolismo venoso. El Dímero D se origina a partir del proceso de fibrinólisis del coagulo mediado por la plasmina. La detección se logra a través de anticuerpos que detectan los antígenos libres de Dímero D. En general, la fortaleza diagnóstica de la prueba se fundamenta en una sensibilidad mayor a 90% y un valor predictivo negativo cercano al 100% cuando se utilizan pruebas de alta sensibilidad en pacientes con probabilidad clínica baja o intermedia de presentar un tromboembolismo venoso. La Sociedad Europea de Cardiología ha revisado la metodología diagnóstica del tromboembolismo pulmonar, sugiriendo el uso del Dímero D en pacientes con baja o intermedia probabilidad clínica de tromboembolismo pulmonar, o en la sala de emergencia, para reducir estudios por imágenes o irradiación innecesaria, excluyendo el tromboembolismo venoso con resultados negativos. Adicionalmente, más allá del rol diagnóstico, existe evidencia que sugiere, que el valor del Dímero D se correlaciona con la probabilidad que distintas patologías protrombóticas desarrollen tromboembolismo venoso. De manera similar, valores elevados parecen correlacionarse con la severidad y mortalidad del tromboembolismo venoso, así como con la recurrencia del mismo al retirarse la medicación anticoagulante. Finalmente, nuevas técnicas para la determinación del Dímero D han sido publicadas y se ha planteado que asociar pruebas que permiten evaluar la activación de la coagulación podría potenciar el valor diagnóstico del Dímero D. La presente revisión evalúa la importancia del Dímero D en el tromboembolismo venoso.

Venous thromboembolism is a common condition in clinical practice. The determination of D-dimer (DD) has been usedas evidence for the diagnosis of venous thromboembolism. The D-dimer originates from the process of clot fibrinolysis mediated by plasmin. Detection is achieved through antibodies that detect antigens D-dimer free. In general, the strength of evidence is diagnosed based on sensitivity greater than 90% and negative predictive value approaching 100% using sensitivity testing in patients with low or intermediate clinical probability of presenting a venous thromboembolism. The European Society of Cardiology has revised the methodology diagnosis of pulmonary embolism, suggesting the use of D-dimer in patients with low or intermediate clinical probability of pulmonary embolism, or in the emergency room, to reduce imaging or radiation unnecessary exclusion of venous thromboembolism with negative results. Additionally, beyond the diagnostic role, there is evidence that suggests that the value of D-dimer is correlated with the probability of developing venous thromboembolism by other prothrombotic pathologies. Similarly, high values appear to correlate with the severity and mortality of venous thromboembolism, as well as recurrence of the anticoagulant medication to withdraw. Finally, new techniques for the determination of D-dimer have been published and has been raised to associate tests to assess coagulation activation could enhance the diagnostic value of D-dimer. This review evaluates the importance of the D-dimer in venous thromboembolism.

Cambios en el flujo venoso de miembros inferiores en pacientes hospitalizados con patologías médicas / Changes in lower limb venous flow in hospitalized patients with medical conditions

La Enfermedad TromboembólicaVenosa (ETV), es diagnosticada muchas veces tardíamente. La mayoría de los casos han sido reportados en pacientes con patologías médicas e inmovilización prolongada. Determinar la relación entre la inmovilización prolongada como factor de riesgo para ETV y su influencia real en el flujo venoso y, los biomarcadores aceptados (Dímero-D). Estudio de cohorte, prospectivo, longitudinal, observacional, de corte transversal, en hospitalizados por patologías médicas, con medición de la velocidad del flujo venoso en miembros inferiores, usando ultrasonografía doppler, correlacionado con el tiempo de inmovilización y niveles de Dímero D a los días 1 y 4 de hospitalización en el Hospital Militar “Dr. Carlos Arvelo”, Caracas, Venezuela. Se obtuvo disminución del flujo venoso de un 20,51± 15,93% al cuarto día (p=0,0002). No se encontró relación entre las variables de disminución en la velocidad de flujo con Dímero D ni con el tiempo de inmovilización. Colateralmente, en las enfermedades metabólicas se presentó disminución marcada del flujo venoso (38,05 ± 10 03%, p=0,003). En el cuarto día de hospitalización se encontraron cambios que pudieran favorecer la aparición de ETV, independientes del tiempo de inmovilización y de los niveles de dímero D; La presencia de enfermedad metabólica o infecciosa se presentó con cambios en el flujo venoso, como un factor de riesgo para ETV

The diagnosis of Venous Thromboembolic Disease (VTD) is often delayed . Most cases have been reported in patients with medical conditions and prolonged immobilization. To determine the relationship between prolonged immobilization as a risk factor for VTD and its influence in venous flow and D- dimer. A prospective, observational study in patients who were hospitalized due to medical conditions, in whom venous flow was measured by Doppler ultrasound and D-dimer on days 1 and 4 of admission. Venous flow was diminished 20,5±15,9 % on day 4 (p= 0,0002). No relationship was found with D-dimer or time of immobilization. In patients who had metabolic and infectious diseases venous flow was markedly diminished (38,05 ± 10 03%, p=0,003.) On the 4th day of hospitalization we found changes that could be a risk factor for VTD independently of the immobilization period or D- Dimer levels. The presence of some metabolic or infectious diseases showed changes in venous flow as risk factor for VT

Anticoagulação durante gravidez de mulher portadora de cardiopatia: [revisão] / Anticoagulation during pregnancy of woman with heart diseases: [review]

Diretrizes em muito contribuem para minimizar os potenciais riscos obstétricos e fetais e melhorar a assistência durante o ciclo gravídico-puerperal. Contudo, há controvérsias a respeito do manuseio da anticoagulação em mulheres portadoras de cardiopatias. A importância deste assunto assenta-se no fato de que o tromboembolismo é considerado uma das principais causas de morte materna em portadoras de cardiopatia, o que torna obrigatório o conhecimento sobre sua prevenção. A estratégia do tratamento antitrombótico é ponderada pelo risco de trombose imposto pela situação clínica materna e pelos efeitos adversos que os anticoagulantes podem causar ao concepto. Neste artigo, serão discutidas a estratificação do risco materno ao tromboembolismo, as propriedades dos anticoagulantes indicados para a sua prevenção e a estratégia terapêutica nos diversos momentos da gestação, parto e puerpério da mulher portadora de cardiopatia.

Guidelines provide great contribution to the reduction of potential obstetric and fetal risks and to the improvement of health care during pregnancy and puerperium. However, there are still controversies regarding the management of anticoagulation in women with heart diseases. The importance of this issue is based on the fact that thromboembolism is considered one of the main causes of maternal death in women with heart diseases; therefore, the acquisition of knowledge about how to prevent this disorder is mandatory. The strategy of the antithrombotic treatment is based on the risk of thrombosis imposed by the maternal clinical picture and on the adverse effects of the anticoagulants for the conceptus. In the present study, we discussed the stratification of maternal risk of thromboembolism, the properties of the anticoagulants indicated for its prevention, and the therapeutic strategy at different moments of pregnancy, delivery and puerperium of women with heart diseases.

Guías para la prevención de enfermedad tromboembólica en pacientes pediátricos: (IV Consenso Venezolano sobre Enfermedad Tromboembólica 2008-2009): [revisión] / Guidelines for the prevention of thromboembolic disease in pediatric patients (IV Consensus on thromboembolic disease Venezuelan 2008-2009): [review]

La Enfermedad Tromboembólica (ETE) en la edad pediátrica ha adquirido mayor importancia, debido al aumento de su incidencia derivada de la optimización de técnicas diagnósticas y terapéuticas. Los episodios de ETE en los niños aparecen de forma brusca y el diagnóstico se hace con métodos incruentos como ecografía doppler, resonancia magnética y estudios angiográficos. Hasta hace poco no se disponía de recomendaciones específicas para el tratamiento de la ETE en el niño; en la actualidad se cuenta con esquemas terapéuticos desarrollados con base en la experiencia con adultos, adaptados a la edad pediátrica. Se revisan las principales patologías y procedimientos susceptibles de producir enfermedad tromboembólica así como las indicaciones de los principales agentes terapéuticos, incluyendo las heparinas, los anticoagulantes orales, antiagregantes y fibrinolíticos y se dan recomendaciones de uso. Dada la morbimortalidad observada en niños afectados por ETE, hay sobradas justificaciones para tomar una actitud activa que intente controlar el proceso y procurar que el beneficio esperado sea siempre superior al riesgo inherente al tratamiento.

Thromboembolic disease (TD) in pediatric patients has gained relevance, due to an increase in its incidence, as a result of the optimization of diagnostic and therapeutic techniques. Episodes of TD in children appear abruptly and diagnosis is carried out through non-invasive methods such as doppler ecography, magnetic resonance imaging and angiography. Until recently, specific recommendations for the treatment of TD in children were unavailable; nowadays, therapeutic schemes developed on the basis of experience with adults adapted to pediatric patients are available. The main pathologies and procedures capable of causing thromboembolic disease were reviewed, as well as the indications of main therapeutic agents, including heparins, oral anticoagulants, platelet antiagregant and fibrinolytic agents. Use recommendations are given. Considering the morbimortality rate observed in children affected by TD, there are plenty of reasons to take an active role to control the process, and seek that expected benefits outweigh the inherent risks of treatment.

Pseudoaneurisma de arteria carótida interna tratado con stent cubierto / Covered stent graft treatment of internal carotid artery pseudoaneurysm

Los pseudoaneurismas de la arteria carótida interna son una complicación poco frecuente de traumatismos penetrantes o cerrados, y por lo general de tratamiento quirurgico difícil, debido a que la resolución por esta técnica requiere de amplia exposición cervical, que puede conllevar a daño de uno o varios nervios craneales o de otras extructuras incluidas las vasculares. El diagnóstico puede retardarse si el traumatismo es no penetrante. El usio de stent cubiertos es relativamente nuevo y lucen como una alternativa atractiva. Los pseudoaneurismas tienen alto riesgo de tromboembolismo por lo qu el diagnóstico oportuno es importante. Los stents cubiertos del tipo autoexpandible surgen como una alternativa interesante al tratamiento quirúrgico, con una tasa muy baja de complicaciones. Es necesario dar al paciente una antiagregaciòn plaquetaria dual (aspirina y clopidogrel) o anticoagulación.

Internal carotid artery pseudo aneurysms are a rare complication following blunt or penetrating trauma and its surgical treatment is difficult, because if they are resolved by surgery they need a large cervical exposure, wich could cause cranial nerve damage or damage of structures, such as the vasculature. The use of stent-graft is relatively new and it appears as an attractive alternative. Pseudo aneurysms have a high risk of thromboembolism, so its early detection is important. Auto-expandable Stent- grafts are an attractive alternative to surgical treatment, with a low incident of complications. It is necessary to give the patient dual antiplatelet treatment (Aspirin plus Clopidogrel) or anticoagulation. There are not studies with follow up to determine its safety and efficacy.

relation between noneacterial thrombotic endocarditis and thromboembolism in patients with cancer

Patients with cancer are in hypercoagulable state. Nonbacterial thrombotic endocarditis [NBTE] can complicate any cancer. The major clinical manifestations of NBTE result from systemic emboli rather than valvular dysfunction. To assess the frequency and echocardiographic characteristics and to determine whether the presence of valvular lesions correlate with thrombo-embolic manifestations [TEM]. A prospective study conducted on 60 patients with different histopathological types of cancer and 10 healthy volunteers. A full medical history taking and physical examination were done and according to the performance status using the WHO score, the patients were classified into two groups of patients; group one, patients with good performance [grade I and II] and group two those with poor performance [III and IV]. Doppler echocardiography, chest-x-ray, abdominal sonography, and laboratory study including complete blood count [CBC]; bleeding time [BT]; prothrombin time and concentration [PT and PC]; Activated partial thromboplastin time [APTT] and serum level of both fibrinogen and D-dimer were done for all participants. Blood culture was done only for patients with NBTE. Doppler study of extremities and computed tomography [CT] of the brain were done for suspected patients with deep venous thrombosis [DVT] and cerebrovascular [CV] stroke respectively, NBTE was detected in 16 out of 60 patients [26.66%]. 22valve lesions were found; the aortic and mitral valves were the commonest sites [12 and 7 lesions respectively]. Valvular regurgitation was found in 12/60 patients [20%]; tricuspid regurgitation [TR] was the commonest lesion [42%]. The incidence of NBTE was higher in patients with poor performance than in those with good performance [p<0.001], and the highest incidence was in patients with adenocarcinoma of pancreas [50%]. Serum level of D-dimer ms higher in patients with NBTE than in those without NBTE [p<0.001]. The incidence of TEM was higher in patients with NBTE than in those without [62.5% versus 6.8%, p<0.001]. NBTE is not uncommon in patients with cancer. Aortic valve was the most commonly affected. Adenocarcinoma was the most frequent histologic type of related cancer. The major clinical manifestations of NBTE result from systemic emboli rather than valvular dysfunction. NBTE should be suspected in any stroke patient with a known or suspected malignancy and anticoagulation with unfractionated or low molecular weight heparin should be used in cancer patients with NBTE

Acute arterial embolism of the lower extremities: impact of 24-hour duration on the outcome of management.

OBJECTIVE: Determine the impact of 24-hour duration of arterial embolism on the outcomes of management. MATERIAL AND METHOD: A prospective study of 91 patients with acute arterial embolism of the lower extremities was carried out. RESULTS: Among the 91 patients, 31(34.1%) were with early acute embolism(< 24 hours) and 60 (65.9%) were with late acute embolism (> 24 hours). Extensive limb gangrene was more common in patients with late acute embolism (26.7% versus 3.2%, p = 0.009). Subsequently, primary major amputation was higher in those patients (20% versus 3.2%, p = 0.05). In early acute embolism, surgical embolectomy was only the primary treatment of revascularization (87.1%) whereas in late acute embolism, there were varying modalities of revascularization (68.3%) in addition to surgical embolectomy. The successful revascularization after the initial surgical embolectomy was significantly higher in patients with early acute embolism (92.6% versus 43.9%, p < 0.001). Patients with late acute embolism had a higher tendency of undergoing major amputation after revascularization (24.4% versus 7.4%, p = 0.106). Successful outcome was higher in patients with early acute embolism (83.9% versus 58.3%, p = 0.014). CONCLUSION: The 24- hour duration of arterial embolism may be a crucial factor influencing the outcome in the management of this disease.

Angiolipoma renal con extensión tumoral a vena cava inferior y aurícula derecha / Left kidney angiomyolipoma, spreading to the renal vein, inferior vena cava and involving the heart: report of one case

El angiomiolipoma renal es un tumor benigno mesenquimático. Constituyen sólo del 2 al 6 por ciento de los tumores renales. Existen alrededor de 12 casos reportados con invasión a las venas renales y la cava inferior. En menos de 5, hay extensión de trombo tumoral hasta aurícula derecha. Objetivo: Presentar el caso clínico, manejo y evolución de una paciente con un angiomiolipoma renal con extensión tumoral a vena renal y cava inferior y que compromete la cavidad auricular derecha casi en su totalidad. Paciente y método: 50 años, sexo femenino con hallazgo del tumor por un ultrasonografía abdominal motivada por el estudio de síntomas digestivos de origen probablemente funcional. Se confirma el diagnóstico con TAC y ecocardiograma doppler. Se realiza una cirugía combinada, abdominal y esternotómica, con la ayuda de un by pass aortopulmonar. Resultados: Nefrectomia izquierda, liberación intravascular del tumor que se empuja por cava inferior y se extrae en block por la aurícula derecha. Evoluciona inicialmente en forma satisfactoria, pero desarrolla distress respiratorio con angio TAC de tórax negativo para TEP a las 48 h de la cirugía. Se inicia anticoagulación empírica con HBPM y encontrándose extubada y en buenas condiciones hace un hemoperitoneo el día 14, encontrándose hemorragia en napa en los sitios de disección previa. De alta a los 21 días. El seguimiento alejado a los 2 años revela una hernia incisional, reparada sin incidentes, y sin otras complicaciones ni signos de recidiva de patología original. Conclusión: El manejo de equipo multidisciplinario nos permitió ayudar exitosamente a esta paciente con patología rara y compleja.

Renal angiomyolipoma is an uncommon benign tumor of mesenchymal origin. In less than five of 12 cases reported with renal vein and inferior vena cava involvement the thrombus extends to the right atrium. We report a 50 years old female with a left kidney angiomyolipoma, spreading to the renal vein, inferior vena cava and involving the heart, invading the right atrium almost completely. The tumor was found during a study for abdominal pain. She underwent combined abdominal and cardiac surgery with pulmonary bypass. A left nephrectomy, cavotomy and intravascular dissection of the tumor were performed. The intravascular mass was pushed from abdomen and pulled out through the right atrium. Forty eight hours after surgery, she developed respiratory distress. A chest angio CT scan negative for pulmonary thromboembolism. However, anticoagulation with low molecular weight heparin was started due to the high risk for thromboembolism. She recovered, but 14 days after the original surgery, presented a massive hemoperitoneum. She was operated again, finding a diffuse oozing from the sites of previous dissection. The dose of anticoagulation was lowered, with a good postoperative evolution, being discharged 21 days later. After two years of follow up, she developed an incisional hernia that is repaired.

Avaliação da adesão ao protocolo de profilaxia de tromboembolismo venoso em pacientes hospitalizados no Hospital de Clínicas de Porto Alegre / Assessment of adherence to thromboprophylaxis protocol in Hospital de Clínicas de Porto Alegre inpatients

Introdução: Trombose venosa profunda (TVP) e tromboembolismo pulmonar (TEP) são problemas importantes em pacientes hospitalizados. Embora o benefício da profilaxia esteja definido, a prescrição baseada em diretrizes continua subutilizada. Este trabalho visa avaliar a utilização da profilaxia de TVP/TEP nos pacientes internados no HCPA e sua concordância com o protocolo assistencial deste hospital. Metodologia: Obteve-se informações do prontuário de todos os pacientes internados no Hospital de Clínicas de Porto Alegre em um dia nas áreas clínicas, cirúrgicas e CTI. Estratificou-se o risco individual para TVP/TEP e comparou-se a profilaxia em uso e a recomendada pelo protocolo assistencial. Resultados: Foram incluídos 265 pacientes, dos quais 46 por cento foram submetidos a procedimento cirúrgico. A maior parte dos pacientes foi estratificada como de risco alto (28,9 por cento) ou muito alto (39,5 por cento). Apenas em 30,7 por cento dos pacientes a profilaxia em uso estava de acordo com aquela recomendada pelo protocolo do HCPA. Conclusão: Os resultados confirmam a subutilização da profilaxia TVP e TEP no nosso meio. A principal discordância entre as prescrições e a profilaxia recomendada pelo protocolo encontra-se no grupo de mais alto risco devido ao pequeno número de prescrições de heparina não-fracionada de 8/8 horas e heparina de baixo peso molecular. Alternativas para aumentar adesão ao protocolo devem ser instituídas

Thromboembolism in chronic Chagas' heart disease

Thromboembolic episodes are particularly important in chronic Chagas' heart disease. Systemic and pulmonary embolic phenomena are important complications of the disease. Prophylaxis of the thromboembolic phenomena with anticoagulant therapy should be considered in several clinical forms of the disease. Further studies will have to address the stratification risk issue.

Tromboembolismo Pulmonar: Monografía / Pulmonary thromboembolims: A monography

El presente documento Tromoembolismo Pulmonar es una de las entidades de la práctica médica, que con mayor frecuencia obliga a la busqueda de la cooperación interdisciplinaria. Basicamente es un proceso que se desarrolla a nivel venosos y a nivel del árbol arterial pulmonar. su frecuencia de presentación es elevada, su diagnóstico, tratamiento y en los tópicos relacionados a trombosis venosa profunda.