Venous thrombus stability during acute phase of therapy

Abstract

The purpose of this study was to use serial venous duplex scans to document the status of deep venous thrombi during the early phase of therapy for acute, deep-vein thrombosis (DVT). A total of 71 consecutive participants treated for a first episode of acute DVT were monitored for new venous thrombosis using serial venous duplex scans. An average of 4.6 duplex scans were performed per patient (range, three to seven) during the 3-week study period. The cumulative incidence of contiguous/non-contiguous extension of the DVT at 3 weeks was 26% (95% CI = 14% to 38%). Nine of the 15 (60%) occurrences were asymptomatic. None of the classical risk factors for DVT was significantly associated with the development of new thrombi. The fraction of time during which the level of anticoagulation was considered `adequate' (international normalized ratio >2.0 and/or heparin concentration >0.2 IU/ml) was inversely associated with the risk of extension/new thrombi (p = 0.01, Cox proportional hazards analysis).

It was concluded that: (1) the frequency of contiguous/non-contiguous extension of venous thrombosis detectable during the first 3 weeks of therapy was higher than previously reported; (2) the majority of the occurrences were asymptomatic; and (3) the risk of developing this complication was inversely associated with the level of anticoagulation achieved.

Keywords

anticoagulants deep-vein thrombosis extension

References

Hull RD , Raskob GE , Rosenbloom D et al. Heparin for 5 days as compared with 10 days in the initial treatment of proximal venous thrombosis. N Engl J Med 1990; 322(18): 1260-1264.

Hull RD , Raskob GE , Rosenbloom D et al. Optimal therapeutic level of heparin therapy in patients with venous thrombosis. Arch Intern Med 1992; 152(8): 1589-1595.

Hull RD , Raskob GE , Hirsh J et al. Continuous intravenous heparin compared with intermittent subcutaneous heparin in the initial treatment of proximal-vein thrombosis. N Engl J Med 1986; 315(18): 1109-1114.

Levine MN , Hirsh J , Gent M et al. Optimal duration of oral anticoagulant therapy: a randomized trial comparing four weeks with three months of warfarin in patients with proximal deep vein thrombosis. Thromb Haemost 1995; 74(2): 606-611.

Levine M , Gent M , Hirsh J et al. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med 1996; 334(11): 677-681.

Pini M , Pattachini C , Quintavalla R et al. Subcutaneous vs intravenous heparin in the treatment of deep venous thrombosis—a randomized clinical trial. Thromb Haemost 1990; 64(2): 222-226.

Hull R , Hirsh J , Jay R et al. Different intensities of oral anticoagulant therapy in the treatment of proximal-vein thrombosis. N Engl J Med 1982; 307(27): 1676-1681.

Hull RD , Raskob GE , Pineo GF et al. Subcutaneous low-molecular-weight heparin compared with continuous intravenous heparin in the treatment of proximal-vein thrombosis. N Engl J Med 1992; 326(15): 975-982.

Raschke RA , Reilly BM , Guidry JR , Fontana JR , Srinivas S. The weight-based heparin dosing nomogram compared with a ‘standard care’ nomogram. A randomized controlled trial. Ann Intern Med 1993; 119(9): 874-881.

10.

Prandoni P , Lensing AW , Buller HR et al. Comparison of subcutaneous low-molecular-weight heparin with intravenous standard heparin in proximal deep-vein thrombosis. Lancet 1992; 339(8791): 441-445.

11.

Killewich LA , Bedford GR , Beach KW , Strandness DEJ. Spontaneous lysis of deep venous thrombi: rate and outcome. J Vasc Surg 1989; 9: 89-97.

12.

Meissner MH , Manzo RA , Bergelin RO , Markel A , Strandness DEJ. Deep venous insufficiency: the relationship between lysis and subsequent reflux. J Vasc Surg 1993; 18: 596-608.

13.

Meissner MH , Caps MT , Bergelin RO , Manzo RA , Strandness DE, Jr. Propagation, rethrombosis and new thrombus formation after acute deep venous thrombosis. J Vasc Surg 1995; 22(5): 558-567.

14.

van Ramshorst B , van Bemmelen PS , Hoeneveld H , Faber JA , Eikel-boom BC. Thrombus regression in deep venous thrombosis. Quantification of spontaneous thrombolysis with duplex scanning. Circulation 1992; 86(2): 414-419.

15.

Wells PS , Hirsh J , Anderson DR et al. Comparison of the accuracy of impedance plethysmography and compression ultrasonography in outpatients with clinically suspected deep vein thrombosis. A two centre paired-design prospective trial. Thromb Haemost 1995; 74(6): 1423-1427.

16.

Ginsberg JS , Wells PS , Hirsh J et al. Reevaluation of the sensitivity of impedance plethysmography for the detection of proximal deep vein thrombosis. Arch Intern Med 1994; 154(17): 1930-1933.

17.

Kearon C , Hirsh J. Factors influencing the reported sensitivity and specificity of impedance plethysmography for proximal deep vein thrombosis. Thromb Haemost 1994; 72(5): 652-658.

18.

Agnelli G , Cosmi B , Radicchia S et al. Features of thrombi and diagnostic accuracy of impedance plethysmography in symptomatic and asymptomatic deep vein thrombosis. Thromb Haemost 1993; 70(2): 266-269.

19.

Agnelli G , Cosmi B , Ranucci V et al. Impedance plethysmography in the diagnosis of asymptomatic deep vein thrombosis in hip surgery. A venography-controlled study. Arch Intern Med 1991; 151(11): 2167-2171.

20.

Lensing AW , Hirsh J. 125I-fibrinogen leg scanning: reassessment of its role for the diagnosis of venous thrombosis in post-operative patients. Thromb Haemost 1993; 69(1): 2-7.

21.

Fauno P , Suomalainen O , Bergqvist D et al. The use of fibrinogen uptake test in screening for deep vein thrombosis in patients with hip fracture. Thromb Res 1990; 60(3): 185-190.

22.

Agnelli G , Radicchia S , Nenci GG. Diagnosis of deep vein thrombosis in asymptomatic high-risk patients. Haemostasis 1995; 25(1-2): 40-48.

23.

Killewich LA , Bedford GR , Beach KW , Strandness DE, Jr. Diagnosis of deep venous thrombosis. A prospective study comparing duplex scanning to contrast venography. Circulation 1989; 79(4): 810-814.

24.

Strandness DE, Jr. Diagnostic approaches for detecting deep vein thrombosis. Am J Card Imaging 1994; 8(1): 13-17.

25.

Comerota AJ , Katz ML , Hashemi HA. Venous duplex imaging for the diagnosis of acute deep venous thrombosis. Haemostasis 1993; 23 (suppl 1): 61-71.

26.

Montefusco von Kleist CM , Bakal C , Sprayregen S , Rhodes BA , Veith FJ. Comparison of duplex ultrasonography and ascending contrast venography in the diagnosis of venous thrombosis. Angiology 1993; 44(3): 169-175.

27.

Tan SS , Chong BK , Thoo FL , Ho JT , Boey HK. Diagnosis of deep venous thrombosis: accuracy of colour Doppler ultrasound compared with venography. Singapore Med J 1995; 36(4): 362-366.

28.

Becker D , Gunter E , Strauss R et al. Color Doppler imaging versus phlebography in the diagnosis of deep leg and pelvic vein thrombosis. J Ultrasound Med 1997; 16(1): 31-37.

29.

Labropoulos N , Leon M , Kalodiki E , al Kutoubi A , Chan P , Nicolaides AN. Colour flow duplex scanning in suspected acute deep vein thrombosis; experience with routine use. Eur J Vasc Endovasc Surg 1995; 9(1): 49-52.

30.

Krupski WC , Bass A , Dilley RB , Bernstein EF , Otis SM. Propagation of deep venous thrombosis identified by duplex ultrasonography. J Vasc Surg 1990; 12(4): 467-474; discussion 474-75.

31.

Wheeler AP , Jaquiss RD , Newman JH. Physician practices in the treatment of pulmonary embolism and deep venous thrombosis. Arch Intern Med 1988; 148(6): 1321-1325.

32.

Prandoni P , Lensing AW , Cogo A et al. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med 1996; 125(1): 1-7.