Assessing the risk of recurrent venous thromboembolism – a practical approach

Jennifer Fahrni,1 Marc Husmann,2 Silvia B Gretener,3 Hong H Keo1 1Division of Angiology, Medical University Clinic, Kantonsspital Aarau AG, Aarau, Switzerland; 2Clinic for Angiology, University Hospital, University of Zurich, Zürich, Switzerland; 3Clinic for Angiology Oberaargau, Langenthal, Switzerland Abstract: Recurrent venous thromboembolism (VTE) is associated with increased morbidity and mortality. This risk is lowered by anticoagulation, with a large effect in the initial phase following the venous thromboembolic event, and with a smaller effect in terms of secondary prevention of recurrence when extended anticoagulation is performed. On the other hand, extended anticoagulation is associated with an increased risk of major bleeding and thus leads to morbidity and mortality. Therefore, it is necessary to assess the risk of recurrence for VTE on an individual basis, and a recommendation for secondary prophylaxis should be specifically based on risk calculation of recurrence of VTE and bleeding. In this review, we provide a comprehensive summary of relevant risk factors for recurrent VTE and a practical approach for assessing the risk of recurrence in daily practice. Keywords: thrombosis, hemorrhage, risk assessment&nbsp

Assessing the risk of recurrent venous thromboembolism - practical approach

Recurrent venous thromboembolism (VTE) is associated with increased morbidity and mortality. This risk is lowered by anticoagulation, with a large effect in the initial phase following the venous thromboembolic event, and with a smaller effect in terms of secondary prevention of recurrence when extended anticoagulation is performed. On the other hand, extended anticoagulation is associated with an increased risk of major bleeding and thus leads to morbidity and mortality. Therefore, it is necessary to assess the risk of recurrence for VTE on an individual basis, and a recommendation for secondary prophylaxis should be specifically based on risk calculation of recurrence of VTE and bleeding. In this review, we provide a comprehensive summary of relevant risk factors for recurrent VTE and a practical approach for assessing the risk of recurrence in daily practice

Diagnostic Accuracy of Fluorescence Microlymphography for Detecting Limb Lymphedema

OBJECTIVES: Fluorescence microlymphography (FML) is a minimally invasive technique for visualization of the cutaneous lymphatic network. The aim of the study was to assess the accuracy and safety of FML in patients with unilateral lymphedema. METHODS: This was a cross sectional study. Patients with unilateral leg swelling were assessed and compared with the unaffected contralateral limb. FML was performed in all index legs and the contralateral leg by injecting 0.1 mL of fluorescein isothiocyanate (FITC)-labeled dextran intradermally in both limbs at the same level. The most prominent swelling of the affected limb was the anatomical reference. The spread of the dye in the lymphatic capillaries of the skin was measured in all dimensions by epiluminator intravital microscopy and the maximum dye spread value 10 min after injection was used for statistical analysis. The contralateral leg served as control. Test accuracy and receiver operator characteristic (ROC) analysis was performed to assess threshold values that best predict lymphedema. RESULTS: Between March 2008 and February 2014 seventy patients with unilateral chronic leg swelling were clinically diagnosed with lymphedema. The median age was 45 (IQR 27-56) years. Of those, 46 (65.7%) were female and 71.4% had primary and 28.6% secondary lymphedema. Sensitivity, specificity, positive and negative likelihood ratio, and positive and negative predictive value were 94.3%, 78.6%, 4.40, 0.07, 81.5%, and 93.2% for the 12 mm cut off level and 91.4%, 85.7%, 6.40, 0.10, 86.5%, and 90.9% for the 14 mm cut off level, respectively. The area under the ROC curve was 0.89 (95% CI: 0.83-0.95). No major adverse events were observed. CONCLUSIONS: FML is an almost atraumatic and safe technique for detecting lymphedema in patients with leg swelling. In this series the greatest accuracy was observed at a cut off level of ≥14 mm maximum spread. Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved

Retrospective analysis of patients for development of nephrogenic systemic fibrosis following conventional angiography using gadolinium-based contrast agents

The purpose was to retrospectively review the data of 27 patients with renal insufficiency who underwent conventional angiography with gadolinium-based contrast agents (GDBCA) as alternative contrast agents and assess the occurrence of nephrogenic systemic fibrosis (NSF) together with associated potential risk factors

Cystic adventitial degeneration: ectopic ganglia from adjacent joint capsules

Cystic adventitial degeneration is a rare non-atherosclerotic cause of peripheral arterial occlusive disease, mainly seen in young men without other evidence of vascular disease. Diagnosis will be established by clinical findings and by ultrasound or angiography and can be treated by excision or enucleation of the affected arterial segment or by percutaneous ultrasound-guided aspiration. However, the etiology of adventitial cysts remains unknown. We report a case of cystic adventitial degeneration showing a connection between the joint capsule and the adventitial cyst, supporting the theory that cystic adventitial degeneration may represent ectopic ganglia from adjacent joint capsules

Impact of long-term corticosteroid therapy on the distribution pattern of lower limb atherosclerosis

OBJECTIVE: Ectopic calcification and mediacalcinosis can be promoted by corticosteroid use. Aim of the present investigation is to describe macrovascular disease features in patients with long-term corticosteroid therapy and symptomatic lower limb peripheral arterial occlusive disease (PAD). METHODS: A consecutive series of 2783 patients undergoing clinical and angiographic work-up of PAD were screened for long-term (>5 years) corticosteroid use (group A). Comparison was performed to a randomly selected age-, sex- and risk factor-matched PAD control cohort from the same series without corticosteroid use (group B). Patients with diabetes mellitus or severe renal failure were excluded. Arterial calcification was evaluated by qualitative assessment on radiographic images. Severity of atherosclerotic lesions was analysed from angiographic images using a semi-quantitative score (Bollinger score). RESULTS: In general, 12 patients (5 males, mean age 78.5 +/- 9.0 years) with 15 ischaemic limbs qualified to be enrolled in group A and were compared to 23 matching control patients (6 2 males, mean age 79.5 +/- 6 years) with 32 ischaemic limbs. Incompressibility of ankle arteries determined by measurement of the ankle-brachial index was seen in 12 limbs (80%) in group A compared to 3 limbs (9%) in group B (p = 0.0009). No significant difference was found comparing group A and B for segmental calcification, whereas comparison of the atherosclerotic burden using the angiographic severity score showed a significantly higher score at the infragenicular arterial level in group A (p = 0.001). CONCLUSION: Findings suggest that the long-term corticosteroid therapy is associated with a distally accentuated, calcifying peripheral atherosclerosis inducing arterial incompressibility. This occlusion pattern is comparable to patients with renal failure or diabetes. Further research is required to support our observations