Meta-analysis and systematic review of interventional therapy versus anticoagulation for isolated femoropopliteal deep venous thrombosis.

OBJECTIVE: Percutaneous endovenous intervention (PEVI) is gaining acceptance for select patients with symptomatic proximal lower extremity deep venous thrombosis (DVT), but the benefits are uncertain in patients with isolated femoropopliteal DVTs. We performed a systematic review and meta-analysis of the literature to assess the safety and effectiveness of PEVI vs systemic anticoagulation for patients with isolated femoropopliteal DVT. METHODS: We systematically searched PubMed, Embase, and the Cochrane Library from inception to March 2018. All studies comparing clinical outcomes between PEVI and systemic anticoagulation were included. The main end points were post-thrombotic syndrome and bleeding complications. Secondary outcomes included femoropopliteal patency rate, venous obstruction, and recurrent DVT. RESULTS: No studies directly comparing PEVI with systemic anticoagulation in isolated femoropopliteal DVTs were identified by the systematic review. A traditional literature review identified one randomized controlled trial comparing the two, which found no difference in rates of post-thrombotic syndrome in PEVI vs systemic anticoagulation (risk ratio, 0.96; 95% confidence interval, 0.82-1.11; P = .56). We additionally identified five retrospective case series containing patients with isolated femoropopliteal DVTs, of which two reported on patency rates (46%-100% at 2 years). CONCLUSIONS: More data are required to definitively state that PEVI should be the preferred intervention for patients with isolated femoropopliteal DVTs, although the initial evidence is promising.

Residual thrombosis after a first episode of proximal deep venous thrombosis.

The aim of this study was to analyse the normalization rate of compression ultrasonography after a first episode of proximal deep venous thrombosis (DVT). Patients underwent compressive ultrasound (C-US) examinations during the 3-6 months following the first proximal DVT episode. Normalization rate of compressive ultrasound (C-US) during the follow-up period was 26.4% [95% confidence interval, 16.3-37.3]. Allelic variation in factor XIII gene (Val34Leu) significantly affected the improvement of popliteal residual thrombi (P = 0.019). We also observed a significant negative correlation between D-dimer levels at 3 months and improvement of popliteal residual thrombi (P = 0.016). There was a significant positive correlation between baseline lumen diameter of the femoral thrombi and IL-8 cytokine (P = 0.015). A significant difference was also found between 1 month-tumor necrosis factor (TNF)-α levels and improvement of residual thrombi (P = 0.047). Our results show that normalization after a standard period of anticoagulation is not frequent and procoagulant and inflammatory biomarkers and also some genetic variations might be related to the resolution of thrombosis.

The development of persistent thrombotic masses in patients with deep venous thrombosis randomized to long-term anticoagulation treatment.

BACKGROUND: The aim of the study was to assess the regression rate of persistent echogenic masses in patients with idiopathic deep venous thrombosis (DVT) who were after initial 6 months randomized to long-term anticoagulation treatment or to discontinuation of anticoagulation. PATIENTS AND METHODS: We followed 168 patients with idiopathic DVT for two years since diagnosis. After 6 months of standard therapy (heparin/LMWH, warfarin with target INR 2-3) we randomized patients with persistent echogenic masses of over 20% of venous diameter to either discontinuation of warfarin or to continuation of warfarin for another 6 months. We evaluated the size of thrombotic masses with duplex ultrasound. RESULTS: After 6 months of standard therapy complete regression was observed in 69 patients while in 99 patients echogenic masses persisted, with 71 patients maintaining an obstruction of at least 20% of venous cross-sectional area. 52 patients were randomized. 27 patients continued warfarin therapy and in 25 patients warfarin was discontinued. After discontinuation of warfarin a further trend to regression was seen in both groups. A significant difference in regression of thrombotic masses between the 6th and 12th month of follow up was seen in patients continuing to receive warfarin, both within the popliteal vein (2.81 +/- 1.56 vs. 2.10 +/- 1.67 mm, p < 0.05) and the femoral vein (3.95 +/- 2.74 vs. 2.30 +/- 1.34 mm, p < 0.05). CONCLUSIONS: After 6 months of DVT treatment persistent echogenic masses can be found in almost two thirds of patients. Even after discontinuation of anticoagulation treatment echogenic masses further regress. However, the rate of regression in patients with deep venous thrombosis between the 6th and 12th month was greater in patients randomized to continue warfarin during this period than in patients without anticoagulation.

Ultrasound assessment of popliteal vein compliance during a short deflation protocol.

The purpose of the present study was to determine whether ultrasound is a useful tool to measure the venous characteristics of the lower extremity during a standard venous collecting cuff deflation protocol. To accomplish this, lower extremity pressure-cross-sectional area (CSA) and pressure-volume relationships were measured in eight (25 +/- 1 yr) supine subjects. Popliteal vein CSA was assessed by using high-resolution ultrasound, while calf volume changes were simultaneously assessed by using venous occlusion plethysmography (VOP). Pressure-CSA and pressure-volume relationships were assessed at baseline, during the cold pressor (CP) test, and following sublingual nitroglycerin (NTG) administration. Relationships were modeled with a quadratic regression equation, and beta(1) and beta(2) were used as indexes of venous compliance. Popliteal vein regression parameters beta(1) (8.485 +/- 2.616 vs. 7.638 +/- 2.664, baseline vs. CP; 8.485 +/- 2.616 vs. 7.734 +/- 3.076, baseline vs. NTG; both P > 0.05) and beta(2) (-0.0841 +/- 0.0241 vs. -0.0793 +/- 0.0242, baseline vs. CP; -0.0841 +/- 0.0241 vs. -0.0771 +/- 0.0280, baseline vs. NTG; both P > 0.05) were not affected by CP or NTG. Similarly, calf regression parameters beta(1) and beta(2), obtained with VOP, were not altered during either trial. Intraclass correlations for venous compliance assessed with ultrasound and VOP were 0.92 and 0.97, respectively, indicating acceptable reproducibility. These data suggest that ultrasound is a functional and reproducible tool to assess the venous characteristics of the lower extremity, in addition to VOP. Additionally, popliteal vein and calf compliance were not affected by the CP test or NTG.

Thrombolysis of acute peripheral arterial and venous occlusions with tenecteplase and eptifibatide: a pilot study.

PURPOSE: To prospectively assess the feasibility, risk profile, and effect on fibrinogen levels of combination tenecteplase (TNK) and eptifibatide in transcatheter thrombolysis for peripheral arterial and venous thromboocclusive disease. MATERIALS AND METHODS: Sixteen consecutive patients (seven men, nine women) seen at our institution between March and August 2002 with arterial (n = 11) or venous (n = 5) thromboocclusive disease were treated with TNK (5-mg bolus and 0.25-mg/h infusion) and eptifibatide (180- micro g/kg bolus and 1- micro g/kg/min infusion). Informed consent was obtained. Technical success was defined as restoration of antegrade flow and more than 95% removal of thrombus. Clinical success in arterial cases was defined as immediate limb salvage and relief of ischemic rest pain, and in venous cases as resolution or improvement in extremity pain and swelling. Major bleeding was defined as an intracranial bleeding episode, bleeding resulting in death, or bleeding requiring transfusion, surgery, or cessation of thrombolytic therapy. RESULTS: Technical success was achieved in 10 of 11 arterial cases (91%) and in four of five venous cases (80%). Clinical success was achieved in nine of 11 arterial cases (82%) and in four of five venous cases (80%). The mean duration of thrombolysis was 12.1 hours +/- 5.8 (range, 2-22 hours), requiring a total TNK dose of 8.0 mg +/- 1.5 (range, 4.0-10.5). A major bleeding episode occurred in one of 16 patients (6.3%) as a result of slow oozing from a femoral groin access site and required transfusion of 2 U of packed red blood cells. There were no deaths, intracranial hemorrhages, remote sites of bleeding, or minor bleeding complications. The serum fibrinogen level decreased to a mean of 59.3% +/- 34.6 of baseline. CONCLUSION: In this initial study, the combination of TNK and eptifibatide was shown to be feasible for peripheral arterial and venous thrombolysis.

Aspirin usage and its influence on femoro-popliteal vein graft patency. The Femoro-popliteal Bypass Trial Participants.

As part of the Femoro-popliteal Bypass Trial patients undergoing femoro-popliteal vein bypass were randomised to aspirin 300 mg and dipyridamole 150 mg twice daily or identical placebo tablets. Blood was taken from a subgroup of 145 patients (mean age 66.3 years) with patent grafts at 6 months. Serum salicylate analysis revealed that of the 65 randomised to receive placebo 18 (28%) had evidence of salicylate in their sample (greater than 50 ng ml-1). Similarly, in those randomised to active treatment and considered to be good compliers 16/61 (26%) had no evidence of salicylate in their serum sample (less than 50 ng ml-1). Analysis of primary graft patency by "intention to treat" failed to detect a difference by life table, the risk being slightly higher in the group assigned to placebo (RR = 1.33, 95% confidence internal C.I. 0.64-2.78, p = 0.438). When comparing patients with no detectable serum concentration (less than 50 ng ml-1) with patients with serum salicylate over 50 ng ml-1 there was a significant difference in graft patency at 66 versus 83% respectively at 3 years (RR = 2.38, 95%C.I. 1.08-5.26, p = 0.024). When corrected for a number of possible risk factors this significant difference was maintained (RR = 2.78, 95%C.I. 1.15-6.67, p = 0.017). Although these findings are based on observational data they provide indirect evidence of an improvement in graft patency with aspirin. This result combined with the finding of a significant reduction in cardiovascular events in the main trial results support the use of aspirin and dipyridamole in patients undergoing femoro-popliteal vein bypass.

[Duplex sonography of the popliteal vein using physiologic conditions and following intravenous administration of dihydroergotamine]. / Duplex-Sonographie der Vena poplitea unter physiologischen Bedingungen und nach intravenöser Gabe von Dihydroergotamin (DHE).

Accurate assessment of blood flow velocities and diameter measurements in veins are possible by duplex-scanning. We used the technique for the measurement of venous blood flow velocity under different physiological conditions and after the administration of dihydroergotamine (DHE). In 15 healthy subjects (mean age 30.4 years) diameter, peak and mean flow velocity of the popliteal vein were measured in lying and standing position before and after intravenous administration of 1 mg DHE. Mean diameter of the popliteal vein was 0.62 +/- 0.06 cm in the recumbent position and was significantly larger in the erect position (0.84 +/- 0.1 cm). Peak flow velocity was 17.4 +/- 4.9 cm/s, mean flow velocity 6.0 +/- 2.4 cm/s in the recumbent subjects. There was a significant decrease (p less than 0.001) of both velocity parameters in erect position. DHE causes a significant (p less than 0.001) decrease in diameter of the popliteal vein (14.5%) at rest and the enlargement was less (p less than 0.001) marked when the subject got up. After DHE administration a statistically insignificant increase in peak and mean flow velocity at rest and a significant (p less than 0.001) increase in mean flow velocity in the upright position was observed. In addition DHE induced a more pulsatile venous flow. This finding may be of importance in the prevention of deep vein thrombosis. Our results show that duplex-scanning allows precise assessment of venous blood flow velocities under different conditions. The technique is useful for direct measurement of the efficacy of vein active drugs.