Travel-related thrombosis (TRT), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), poses a significant health risk associated with long-haul travel. Prolonged immobility, dehydration, and cabin pressure changes during flights contribute to venous stasis, hypoxia, and hypercoagulability, collectively increasing the risk of venous thromboembolism (VTE). While the absolute risk of TRT is relatively low in the population overall, it rises significantly among high-risk groups, including individuals with a history of VTE, thrombophilia, pregnancy, or recent surgery. This review explores the epidemiology, pathophysiology, clinical presentation, and diagnostic evaluation of TRT while highlighting the importance of early recognition and prevention. Risk assessment models can provide guidance for identifying at-risk travelers. Preventive strategies include pharmacological prophylaxis with low-molecular-weight heparin (LMWH) for high-risk individuals and nonpharmacological measures such as compression stockings, intermittent pneumatic compression, mobility exercises, and hydration. Guidelines from international societies recommend tailored interventions based on individual risk profiles, as randomized controlled trials are scarce. Given that long-haul travel dramatically expands, this review critically analyzes the available TRT management strategies in various clinical settings, aiming to increase awareness of this global health issue.

Up to now, the indications of inferior vena cava filter placement still remain controversial in the academic field. The aim of this study was to determine the risk factors of detachment of thrombus and to evaluate the necessity of inferior vena cava filter placement to prevent fatal pulmonary embolism.

A total of 2892 patients participated in the multicenter prospective observational study from January 1, 2018, to December 31, 2018, and underwent retrievable inferior vena cava filter (RIVCF) placement in 103 centers in China. The primary endpoint of the study was RIVCF trapped embolus detected by inferior vena cava venography/ultrasound/computed tomography scanning or visible macroscopic thrombus before or during RIVCF retrieval. The relative factors of RIVCF trapped embolus were analyzed accordingly.

The average age of the patients was 61.0 (50.0-71.0) years. Retrievable inferior vena cava filter trapped embolus occurred in 308 patients (10.65%). The fracture location, surgery location, and endovascular intervention differed between RIVCF trapped embolus and non-RIVCF trapped embolus groups (p<0.001, respectively). By multivariate analysis, RIVCF trapped embolus were less common in older patients (odds ratio [OR]=0.998; p<0.001) and more common in patients with below-the-knee fracture (OR=1.093, p=0.038), thigh fracture (OR=1.118, p=0.007), and pelvis surgery (OR=1.067, p=0.016). In addition, compared with patients without endovascular intervention, patients with percutaneous mechanical thrombectomy (PMT) + catheter-directed thrombolysis (CDT) were more prone to develop RIVCF trapped embolus (OR=1.060, p=0.010). However, RIVCF trapped embolus was less common in patients with CDT (OR=0.961, p=0.004).

Lower limb fracture, pelvis surgery, and PMT + CDT are prone to cause trapped embolus. As a trapped embolus often represents the possibility of severe pulmonary embolism, lower limb fracture, pelvis surgery, and PMT + CDT could be risk factors of fatal pulmonary embolism. Due to the low incidence of trapped embolus, it is not necessary to place filters in elderly patients and CDT-only patients.Clinical ImpactThe purpose of this paper is to standardize the use of inferior vena cava filter and avoid unnecessary filter implantation through the summary and analysis of a large number of clinical data. At the same time, more attention should be paid to and active treatment should be given to high-risk groups of pulmonary embolism.

The management of cancer-associated isolated superficial venous thrombosis (iSVT) remains controversial as cancer patients are at higher risk of bleeding and venous thromboembolism (VTE).

We performed a systematic review and meta-analysis to determine the incidence and risk of VTE in patients with iSVT and active malignancy.

Medline, Embase, Web of Science, and the Cochrane Library were searched from inception to December 2, 2024, to identify studies investigating VTE rates in adult patients with iSVT and active malignancy. The incidence of VTE in patients with active malignancy and iSVT was pooled by meta-analysis and compared to patients with iSVT without active malignancy. Secondary outcomes included the incidence of major bleeding, clinically relevant nonmajor bleeding, hospitalization, and all-cause death.

Eight full-text studies were included, comprising 5998 iSVT patients and 448 with active malignancy. Patients with cancer-associated iSVT had an overall incidence of VTE of 18.2 events per 100 patient years (95% CI, 5.2-31.2; I2 = 76%) and a higher rate of VTE compared to patients with iSVT without active malignancy (risk ratio, 2.57; 95% CI, 1.78-3.71; I2 = 0%; P < .001). There were 2 major bleeding events per 100 patient years (95% CI, 0-6.7; I2 = 59%) and 22.8 deaths per 100 patient years (95% CI, 0-58.7; I2 = 73%) for cancer-associated iSVT. Only 1 study reported on clinically relevant nonmajor bleeding and hospitalization rates, respectively.

Patients with iSVT and active malignancy have high rates of VTE despite treatment. Future studies should investigate the role of extended duration anticoagulation on VTE rates in this population.

Limited data exist on persons with rare bleeding disorders possessing a heterozygous genotype, as most studies focus on biallelic genotypes and more severe coagulation factor deficiencies. A growing body of evidence suggests that persons with a heterozygous genotype experience clinically relevant bleeding symptoms.

This study aimed to explore the incidence of bleeding symptoms and postoperative bleeding in persons with a heterozygous genotype.

This cross-sectional substudy of the Rare Bleeding Disorders in the Netherlands study (2017-2019) included persons with rare coagulation factor deficiencies and disorders of fibrinolysis with a heterozygous or biallelic genotype. Clinical data and laboratory samples were collected during a single study visit along with questionnaires.

In total, 86 persons with a heterozygous genotype and 55 with a biallelic genotype were included. Median factor activity levels in persons with a heterozygous genotype approached 50% with considerable heterogeneity (range, 11%-93%). In 75%, persons with a heterozygous genotype reported bleeding severity of grade II or III. Female-specific bleeding was common. In total, 425 surgical procedures were performed. Persons with a heterozygous genotype were less likely to receive periprocedural treatment, and omission of periprocedural treatment was associated with postoperative bleeding in procedures with intermediate-high bleeding risk. Postoperative bleeding was comparable for persons with a heterozygous genotype (35%; 59/171) and a biallelic genotype (35%; 86/247; P = .926).

In our population with rare bleeding disorders, the majority of persons possessing a heterozygous genotype exhibited spontaneous bleeding symptoms. Especially in intermediate-high risk procedures, a proactive approach to periprocedural hemostatic treatment in persons with a heterozygous genotype seems beneficial.

Venous thromboembolism (VTE) remains a significant global health burden, particularly in older adults. While fondaparinux sodium, enoxaparin sodium, and dalteparin sodium are commonly used anticoagulants, their safety profiles require further evaluation. This study analyzes their adverse drug events (ADEs) using data from the FDA Adverse Event Reporting System (FAERS). A retrospective pharmacovigilance study was conducted using FAERS data from Q1 2004 to Q2 2024. Reports identifying fondaparinux sodium, enoxaparin sodium, or dalteparin sodium as the primary suspect drug were extracted. ADEs were classified using MedDRA 23.0 at the System Organ Class (SOC) and Preferred Term (PT) levels. Disproportionality analysis was performed with Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Multi-item Gamma Poisson Shrinker (MGPS). FAERS contained 470 reports for fondaparinux sodium, 1,375 for enoxaparin sodium, and 344 for dalteparin sodium. Most cases involved patients aged ≥ 60, with a female predominance. Hospitalization was the most frequent outcome. Fondaparinux showed the strongest signals for intra-abdominal haematoma (ROR = 374.14, PRR = 371.14), muscle haemorrhage (ROR = 354.91, PRR = 347.04), and retroperitoneal haematoma (ROR = 214.97, PRR = 213.25). Enoxaparin demonstrated notable signals for heparin-induced thrombocytopenia (HIT) (ROR = 149.42, PRR = 147.53) and retroperitoneal haemorrhage (ROR = 287.68, PRR = 284.03). Dalteparin showed notable signals for HIT (ROR = 127.88, PRR = 126.49) and retroperitoneal haemorrhage (ROR = 103.23, PRR = 102.75). Distinct ADE profiles were identified among the three anticoagulants, underscoring the need for individualized risk assessment. These findings highlight the importance of close monitoring, particularly in high-risk patients, to optimize anticoagulation safety.

ObjectiveThe incidence, risk factors, and clinical presentation of deep venous thrombosis (DVT) vary with age. This study aimed to evaluate the differences in clinical characteristics of DVT among patients of different ages.MethodsWe retrospectively analyzed 938 patients with symptomatic lower extremity DVT admitted to our hospital between January 2020 and January 2024. Patients were categorized into youth (<40 years), middle-aged (40-64 years), and elderly (>65 years) groups. Demographic data, comorbidities, risk factors, clinical presentations, and management approaches were collected and analyzed.ResultsMost participants were middle-aged or elderly, with young patients constituting only 11.19% of the study population. The youth group had a slight female predominance, while the middle-aged and elderly group had a balanced gender distribution. The elderly group were more likely to have comorbidities such as diabetes and malignancies, though they had a lower prevalence of autoimmune diseases compared to younger patients. Congenital risk factors were relatively rare in the overall population, yet were present in 22.86% of young patients, a significantly higher proportion than in the middle-aged and elderly groups. Most patients with DVT were provoked, especially in the elderly group. The prevalence of concurrent congenital and acquired factors was 13.33% in the youth group, compared to only 4.97% in the middle-aged group and 2.88% in the elderly group. Proximal DVT was most frequent in middle-aged patients, while young patients were more likely to seek treatment in the acute phase and undergo surgical intervention. Anticoagulation noncompliance was noted in nearly 40% of elderly patients but only 6.67% of young patients.ConclusionRisk factors and clinical characteristics of DVT vary significantly with age, particularly between young and elderly patients. Young patients were more inclined to seek prompt and effective treatment and demonstrated better adherence to anticoagulation therapy.

ObjectivesSuperficial venous thrombosis (SVT) is an acute thrombosis affecting the superficial venous system, characterized by inflammation of the venous wall. While much research has focused on deep vein thrombosis (DVT), SVT has historically been neglected due to its reputation as a benign and self-limiting condition.MethodsA literature search was conducted using PubMed and Google Scholar from January 2000 to December 2023, focusing on English-language publications and including original articles, systematic reviews, and randomized controlled trials. The following keywords were used in various combinations: "superficial venous thrombosis," "superficial thrombophlebitis," "phlebitis," and "thrombophlebitis." The review aimed to analyze SVT, discuss its key features, treatment approaches, and prognosis. We identified 133 potentially relevant records, of which 98 were screened in full text; 39 met our inclusion criteria (i.e., adult populations, clinical data on SVT incidence, risk factors, and treatment outcomes). A PRISMA-style flowchart illustrates the selection process and reasons for exclusion (e.g., duplication, lack of relevant endpoints).ResultsSVT is a common but often underestimated condition that can lead to complications, including pulmonary embolism. The mainstay treatment consists of anticoagulant therapy, starting with low-dose unfractionated heparin or fondaparinux as the first-line drug, progressing to oral anticoagulants at therapeutic doses in more extensive cases. The diagnosis is primarily clinical but should be confirmed by color Doppler ultrasound. Furthermore, SVT may be indicative of serious underlying conditions.ConclusionsWhile often considered benign, SVT is a deceptive pathology. If not properly diagnosed and treated, it can progress to DVT and associated complications. Additionally, SVT may signal significant systemic conditions such as malignancies, hereditary thrombophilia, and cardiovascular diseases, warranting further investigation by clinicians.

Massive pulmonary embolism (PE) is a disease with high mortality, therefore early diagnosis and treatment is essential to save lives. In the absence of contraindications, patients with massive PE (high risk) should be treated immediately with full-dose intravenous systemic thrombolysis. The subset of patients for whom systemic thrombolysis is not successful and who continue to present with haemodynamic compromise or those with contraindications may be candidates for various catheter-directed or surgical therapies. The decision algorithm in intermediate-high/submassive risk patients is complex and must be employed by a multidisciplinary team and success may depend on the experience of the medical specialists involved.

Portal venous system aneurysms (PVAs) are increasingly diagnosed on cross-sectional computed tomography imaging. However, the natural history of these aneurysms is poorly understood, and reports are limited to small case series.

Terms relevant to PVAs were searched in radiology reports (2010-2022), with PVA presence confirmed by manual review. PVA were defined as a diameter greater than 1.5 cm in patients without cirrhosis and 1.9 cm in those with cirrhosis. Aneurysm growth was defined as greater than 20% increase in size, whereas aneurysm regression was defined as greater than 20% decrease in size. Patient demographics, comorbid conditions, and PVA outcomes were abstracted. Univariate statistics were used to compare groups.

Thirty-eight aneurysms with radiographic follow up were identified in 35 patients, involving the portal vein (n = 18; 47.4%), splenic vein (n = 10; 26.3%), superior mesenteric vein (n = 3; 7.9%), and portal confluence (n = 7; 18.4%). Although 12 (31.6%) were idiopathic, the remaining 26 (68.4%) were associated with portal hypertension (n = 20; 52.6%) and prior liver transplant (n = 4; 10.5%). The median growth was 0.2 cm (range, -2.6 to 2.4 cm) over median follow up over 5.0 years (range, 0.3-16.6 years). Five PVAs (13.2%) regressed and were largely idiopathic (80.0%; P = .03). Thirteen PVAs (34.2%) grew and were associated with portal hypertension (n = 11; 84.6%; P = .003) and thrombosis (n = 6; 46.2%; P = .05). Nine PVAs (23.7%) thrombosed, predominantly in males (n =7; 77.8%). The median growth was 1.0 cm (range, -0.7 to 1.9 cm). Three patients (33.3%) were symptomatic from PVA thrombosis including abdominal pain (n = 2; 22.2%), intestinal ischemia (n = 1; 11.1%), and variceal bleeding (n = 2; 22.2%). Four patients (44.4%) were treated with anticoagulation. No aneurysms ruptured. Of the 58 PVAs initially identified with and without radiographic follow up, five (8.6%) underwent intervention with a median diameter of 4.0 cm (range, 3.4-5 cm). Intervention included vein ligation (n = 1; 20.0%), aneurysmorrhaphy (n = 1; 20.0%), and aneurysmectomy (n = 3; 60.0%). There was one case of aneurysm recurrence 20 years following resection and one postoperative mortality.

Two-thirds of PVAs, including those with size greater than 3 cm, remain stable on surveillance. Although annual surveillance is initially recommended to confirm PVA stability, interval imaging can be subsequently extended given low growth rates. Over 20% of PVAs thrombosed, but none ruptured. Although we did not observe any cases of rupture, the devastating consequences of rupture necessitate consideration of surgical intervention for large symptomatic PVAs.

ObjectivesTo investigate the prevalence, clinical characteristics and risk factors of hospital acquired venous thromboembolism (HA-VTE) in a Chinese Hospital.MethodsRetrospective analysis of patients diagnosed as HA-VTE in a single institution from January 2016 to December 2022 was performed. Patients with VTE prior to admission or within 48 h after admission were excluded. Demographic data of patients was retrieved from the electronic medical database, and parameters affecting the occurrence of HA-VTE were analyzed.Results4,022 patients from 321,997 episodes of medical admissions were diagnosed as VTE. Among these, 952 (23.7%) fulfilled the criteria of HA-VTE, corresponding to an incidence of 0.296%. 76% of patients presented with HA-deep vein thrombosis (DVT) alone, 13% presented with isolated HA-pulmonary embolism (PE), and 11% presented with concomitant HA- DVT and PE. Risk factor analyses showed statistically higher incidence in patients with elder age (67.5 ± 15.5 vs 48.3 ± 17.2 years, p < .001), male gender (0.346% vs 0.262%, p < .001), malignancy (0.513% vs 0.252%, p < .001), trauma (0.659% vs 0.28%, p < .001), emergency admission (0.664% vs 0.186%, p < .001), ICU stay (2.981% vs 0.226%, p < .001), and patients undergoing major surgery (0.702% vs 0.176%, p < .001). Patients with HA-VTE had longer hospital stay (22.5 ± 26.6 vs 7.21 ± 9.23 days, p < .001) and higher mortality rate (8.51% vs 1.01%, p < .001). The crude incidence rate of HA-VTE increased annually from 0.75 per 1,000 patients in 2016 to 5.89 per 1,000 patients in 2022. The subspecialties with the highest incidence rate of HA-VTE were cardiovascular surgery (1.40%), neurosurgery (1.10%), and respiratory medicine (0.72%).ConclusionThis is one of the few large scale studies to show that HA-VTE, accounting for nearly one quarter of all VTE events, occurs in 0.296% of adult hospitalizations. Patients with elder age, malignancy, ICU stay, and undergoing major surgery require more intensive HA-VTE surveillance and prevention.

Orthopedic and vascular surgeries carry a high risk of postoperative deep vein thrombosis (DVT). This cross-sectional study assessed the knowledge, attitude, and practice (KAP) of orthopedists, vascular surgeons, and anesthesiologists regarding postoperative DVT prevention in surgical patients. The study was performed at two hospitals in China from November 22 to December 13, 2023. Demographic information and KAP data were collected using a self-administered questionnaire. Among 294 doctors, 187 (63.61%) were male, and 248 (84.35%) had prior experience in orthopedic surgeries. Mean scores for knowledge, attitude, and practice were 9.94 ± 1.91, 37.12 ± 2.94, and 23.02 ± 3.64, respectively. Knowledge was correlated to attitude (r = 0.182, P = 0.002), knowledge to practice (r = 0.234, P < 0.001), and attitude to practice (r = 0.281, P < 0.001). Attitude score (OR = 1.249, 95% CI: [1.127-1.385], P < 0.001) and anesthesiology work (OR = 0.309, 95% CI: [0.158-0.603], P = 0.001) were independently associated with proactive practice. Structural equation modeling confirmed direct impacts of knowledge on attitude (β = 0.894, P < 0.001) and practice (β = 1.786, P < 0.001) and of attitude on practice (β = 0.338, P = 0.017). In conclusion, orthopedists, vascular surgeons, and anesthesiologists showed good knowledge, attitude, and practice toward DVT prevention in surgical patients in two hospitals in China.

Background: Lymphomas account for approximately 10% of cancers diagnosed during pregnancy, with Hodgkin's lymphoma being the most common. However, non-Hodgkin lymphomas, including primary mediastinal large B-cell lymphoma (PMBCL), also represent a significant proportion. Both mediastinal lymphomas and pregnancy develop a hypercoagulable state, increasing the risk of venous thromboembolism and massive pulmonary embolism (PE), requiring extracorporeal membrane oxygenation (ECMO). Methods: Clinical data, blood test and imagings have been collected by the medical records of the patient. Results: We present a 25-year-old woman, at 32 weeks of gestation, who presented to the emergency department with progressive dyspnea and asthenia. Echocardiography revealed a hemodynamically significant pericardial effusion and severe right ventricular dysfunction. Given the severity of her condition, she underwent an emergency caesarean section and subsequently a pericardial drainage. A chest computed tomography scan revealed an incidental mediastinal mass along with a massive PE. Despite pericardial drainage, she remained hemodynamically unstable. Since thrombolysis was contraindicated for the recent cesarean section, venoarterial ECMO was initiated. Systemic anticoagulation was guaranteed by heparin, which shifted to argatroban for heparin resistance. The mediastinal mass was also biopsied, and the diagnosis of PMBCL carried out. Cytoreductive chemotherapy was initiated with the COMP-R regimen (i.e., cyclophosphamide, vincristine, methotrexate, prednisone, and rituximab), and the patient progressively improved up to ICU and hospital discharge. Conclusions: This case highlights the challenges in managing a complicated patient requiring early multidisciplinary intervention, which was crucial for stabilizing the patient and optimizing fetal and maternal prognosis.

This study investigated the effectiveness of catheter-directed thrombolysis (CDT) combined with intermittent pneumatic compression (IPC) in patients with lower extremity deep venous thrombosis (LEDVT).

A retrospective analysis was conducted on 68 LEDVT patients. Those who received CDT with IPC were assigned to the IPC group, while those who underwent CDT alone were designated as the control group. Both groups were further divided into early and late subgroups based on the time from symptom onset to CDT. Data collected included the cumulative urokinase dosage, CDT duration, and other relevant clinical indicators.

The cumulative urokinase dosage was lower in the IPC group than in the control group (P<0.05). CDT duration was shorter in the IPC group than in the control group and was also shorter in the early subgroup compared with the late subgroup (all P<0.05). The peak D-dimer occurred earlier in the IPC group than in the control group (P<0.05). The incidence of grade II-III thrombolysis was higher in the IPC group than in the control group on days 2 and 3 of CDT (all P<0.05). The IPC group showed a greater reduction in thigh and calf circumference than the control group on days 3 and 4 of CDT (all P<0.05).

In LEDVT patients, CDT combined with IPC reduced the cumulative urokinase dosage, shortened CDT duration, promoted earlier deep vein patency, and accelerated the relief of lower extremity swelling.

Transcutaneous Electrical Acupoint Stimulation (TEAS) is a non-invasive therapeutic approach that combines modern electrophysiological technology with traditional Chinese medicine principles. Over the past few decades, TEAS has become a significant medical intervention during the perioperative period and its mechanisms have seen a continuous development. These mechanisms span across multiple aspects, including the regulation of the neuroendocrine network system, inhibition of oxidative stress, alleviation of immune suppression, regulation of endothelial function, and inhibition of coagulation and fibrinolysis system activation. This article aims to summarize and elaborate the mechanisms of TEAS in the perioperative period and to discuss current research challenges. Future studies should strive to optimize treatment protocols to promote the research on the mechanisms of TEAS in the perioperative period, subsequently offering patients safer and more effective treatment alternatives.

Venous thromboembolism (VTE) is a common complication in patients with traumatic brain injury (TBI). This study aimed to assess the predictive ability of the Caprini score, Risk Assessment Profile for Thromboembolism (RAPT), and Trauma Embolic Scoring System(TESS) for VTE risk assessments in TBI patients. A retrospective analysis of 460 TBI patients was conducted, categorizing them into VTE and non-VTE groups based on imaging results. The three scales were applied to assess VTE risk, and their performance was compared using receiver operating characteristic(ROC) curves and area under the curve(AUC) values. The VTE incidence was 31.7%. The RAPT scale demonstrated the highest AUC (0.826) and optimal cutoff (9.5) with balanced sensitivity (0.753) and specificity (0.771). The Caprini and TESS scales also showed moderate to high predictive value but had lower AUCs. All three scoring scales showed medium to high predictive value for the risk of VTE in patients with TBI. Among them, the RAPT scoring scale offered the highest predictive value for VTE risk in TBI patients, with fewer items, making it easier for clinical implementation. It stands as the most appropriate VTE risk assessment scale for TBI patients at present.

Venous thromboembolism (VTE) can lead to significant healthcare resource utilization (HcRU) and costs. First-line treatments such as direct-acting oral anticoagulants (DOAC) and low molecular weight heparin (LMWH) are utilized for VTE management. There are limited observational studies to determine which first-line drug for VTE is associated with lower HcRU and cost. Therefore, we sought to compare HcRU and costs of commercially insured patients with VTE who initiated DOAC or LMWH in the US.

We utilized Merative MarketScan Research Database (2016-2021) to identify adults initiating DOAC or LMWH for VTE. Baseline measures were assessed 12 months prior to the index date of drug initiation. Inverse probability of treatment weighting was used to control confounding. For HcRU, logistic regression was used to model emergency room and inpatient visits and the negative binomial count model was used for outpatient visits. The average marginal effect for total healthcare cost comparing DOAC with LMWH users was estimated using a generalized linear model. HcRU and costs were evaluated for 12 months posttreatment initiation.

DOAC users had lower odds of inpatient visits (adjusted odds ratio [aOR] 0.53, 95% CI 0.46 to 0.59), emergency room visits (aOR 0.86, 95% CI 0.73 to 0.99), and outpatient visits (adjusted incident rate ratio 0.52, 95% CI 0.50 to 0.54) in comparison to LMWH users. DOAC users had lower total healthcare costs of -$9573 (95% CI -$11,149 to -$7997) (US dollars).

This cohort study suggests that DOAC use is associated with fewer inpatient, outpatient, and emergency room visits, and lower healthcare costs compared to LMWH use for VTE management.

BACKGROUND Chronic inferior vena cava (IVC) occlusion is a serious long-term complication of inferior vena cava filters (IVCFs) placement, which can lead to severe post-thrombotic syndrome (PTS). Endovascular management associated with anticoagulation may be one of limited options. Here, we present 3 patients with chronic filter-associated IVC occlusion managed with endovascular stenting and Factor Xa inhibitor infusion. CASE REPORT Case 1: A 48-year-old man who presented bilateral lower-extremity swelling, hyperpigmentation, and refractory venous ulcerations with a permanent IVCFs placements 16 years before admission was diagnosed as having filter-associated chronic IVC occlusions. Recanalization was performed through endovascular therapy, and factor Xa inhibitor was selected for antithrombotic therapy. Although in-stent occlusion was discovered on the left limb during 1-year follow-up, relief of symptoms was achieved at 36-month follow-up. Case 2: A 75-year-old man with a 6-year history of bilateral lower-extremity swelling, hyperpigmentation, and refractory venous ulcerations was found to have chronic IVC occlusions due to permanent IVCFs. Endovascular therapy and factor Xa inhibitor were chosen for revascularization, and symptomatic relief and stents patency were maintained until the last follow-up (30 months). Case 3: A 46-year-old man diagnosed with filter-associated chronic IVC occlusions underwent endovascular stenting and factor Xa inhibitor infusion. Improvement was shown during the first-year follow-up, but recurrence of symptoms and in-stent occlusions were discovered at 18-month follow-up for anticoagulation withdrawal. CONCLUSIONS Despite risks of in-stent occlusions, factor Xa inhibition associated with endovascular may be a safe and feasible management of filter-associated chronic IVC occlusion.

Introduction: Previous studies have shown that the manufacturer's standard fixed dosing of enoxaparin for venous thromboembolism (VTE) prophylaxis leads to sub-prophylactic anti-Xa levels in medicine patients with obesity. Yet, there is limited literature describing higher dosing strategies in this patient population, and an optimal dosing regimen has not been well-established. Objective: The primary objective was to evaluate mean doses (mg/kg/d) of prophylactic enoxaparin that are associated with goal anti-Xa levels in medicine patients with obesity across 3 body mass index (BMI) groups (40-49 kg/m2, 50-59 kg/m2, ≥60 kg/m2). Methods: This is a single-center, retrospective cohort study of adult patients (age ≥18 years) with BMI ≥40 kg/m2 admitted to a medicine team with at least 1 appropriately drawn anti-Xa level between January 2018 and July 2023. The institution's goal anti-Xa level for VTE prophylaxis was 0.2 to 0.4 units/mL. The primary outcome was the comparison of mean dose between those within anti-Xa at goal and not at goal. Secondary outcomes included the percentages of initial anti-Xa levels below, within, or above goal range and the incidence of new VTE and major bleeding events during hospitalization while on enoxaparin. All outcomes were stratified into 3 BMI groups: 40-49 kg/m2, 50-59 kg/m2, and ≥60 kg/m2. Results: Median dose of those with final anti-Xa level at goal was significantly higher than that of those not in goal anti-Xa range across all 3 BMI groups (0.57 vs 0.50 mg/kg/d; P < 0.05). The majority of the initial anti-Xa levels were subprophylactic, with only 35.7% of patients (or 75 of 210 patients) had initial anti-Xa within the goal range. There were no statistically significant differences in the number of blood transfusions or VTE events between the groups. Conclusion: Findings suggest that medicine patients with BMI ≥40 kg/m2 may require enoxaparin doses higher than 0.5 mg/kg/d to reach goal prophylactic anti-Xa level. However, more robust data are necessary to further validate these results and the clinical implications.

Decompressive craniectomy (DC) is a critical surgical intervention for elevated intracranial pressure. However, the impact of preoperative antiplatelet or anticoagulant therapy on outcomes and complications remains unclear. A retrospective-prospective study was conducted on 145 patients undergoing DC between November 2021 and May 2023. Patients were categorized into two groups: those with (n = 48) and without (n = 97) preoperative antithrombotic therapy. Demographic data, comorbidities, antithrombotic therapy type and duration, clinical outcomes, and pre-operative risk factors (CHA2DS2-VASc and HAS-BLED scores) were analyzed. While there was a trend towards higher hemorrhagic complications in the antithrombotic therapy group (20.0% vs. 11.3%), this difference was not statistically significant. However, thromboembolic events, primarily stroke (27.7% vs. 9.3%) and acute myocardial infarction (10.6% vs. 0.0%), were significantly more frequent in the antithrombotic therapy group. Multivariate analysis revealed that ischemic stroke as a primary diagnosis, rather than antithrombotic therapy itself, was a significant predictor of thromboembolic complications (adjusted OR 3.49, 95%CI 1.47-8.28, p = 0.005). Pre-operative GCS was associated with improved outcomes (adjusted OR 0.81, 95%CI 0.67-0.97, p = 0.025). While antithrombotic therapy does not appear to increase the risk of hemorrhagic complications after DC, it is associated with a higher risk of thromboembolic events, especially in patients with ischemic stroke. Individualized assessment and tailored management of antithrombotic therapy are crucial to optimize outcomes in DC patients. Further studies are needed to refine strategies for bridging anticoagulation and managing antithrombotic therapy in this population, considering factors such as CHA2DS2-VASc and HAS-BLED scores, as well as patient-specific risk profiles.

Lower extremity deep venous thrombosis (LEDVT) is a common complication in patients with acute hemorrhagic stroke, leading to increased risk of pulmonary embolism, disability, and mortality. Despite its importance, LEDVT often goes undetected in clinical practice, and early preventive strategies remain insufficient. This study aimed to explore the incidence of LEDVT in acute hemorrhagic stroke patients, identify key risk factors, and discuss potential preventive measures to reduce its occurrence and improve patient outcomes. A retrospective analysis was conducted on 431 acute hemorrhagic stroke patients admitted to The First Affiliated Hospital of Chengdu Medical College between January 2022 and December 2023. Relevant clinical data, including patient demographics, comorbidities, NIHSS score, and treatment history, were collected. LEDVT was diagnosed using standardized ultrasound criteria. Statistical analyses, including univariate and multivariate logistic regression, were performed using SPSS 17.0 to identify independent risk factors associated with LEDVT. The incidence of LEDVT among the 431 acute hemorrhagic stroke patients was 12.1%, with 52 cases identified. Significant risk factors for LEDVT included advanced age, diabetes, infection, prolonged bed rest, high-dose diuretic use, NIHSS score ≥16, and hyperlipidemia (P < .05). Gender, smoking history, and alcohol consumption were not found to be statistically significant. Multivariate logistic regression revealed that advanced age, diabetes, infection, prolonged bed rest, high-dose diuretic use, NIHSS score ≥16, and hyperlipidemia were independent risk factors for LEDVT. LEDVT in acute hemorrhagic stroke patients is influenced by multiple factors, including comorbidities, severity of neurological impairment, and treatment regimens. Dehydration therapy used for managing brain edema and intracranial pressure was also found to be an independent risk factor. Given the significant impact of LEDVT on patient prognosis, early identification of at-risk patients and the implementation of proactive preventive measures-such as pharmacological treatments and physical interventions-are critical in reducing the occurrence of LEDVT, alleviating patient suffering, and improving long-term outcomes. Future studies should focus on refining preventive strategies and exploring more individualized interventions to further reduce the incidence of LEDVT in these patients.

Pulmonary embolism (PE) is relatively common worldwide. It is a serious condition that can be life-threatening. Studies on the relationship between adverse outcomes of this condition and whether a patient is male or female have yielded inconsistent results. Determining whether there is an association between sex and short-term mortality in patients with acute PE is important as this information may help guide different approaches to PE monitoring and treatment.

To determine whether sex (i.e. being a male or a female patient) is an independent prognostic factor for predicting mortality in adults with acute symptomatic pulmonary embolism.

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register up to 17 February 2023. We scanned conference abstracts and reference lists of included studies and systematic reviews. We also contacted experts to identify additional studies. There were no restrictions with respect to language or date of publication.

We included phase 2-confirmatory prognostic studies, that is, any longitudinal study (prospective or retrospective) evaluating the independent association between sex (male or female) and mortality in adults with acute PE.

We followed the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of prognostic factor studies (CHARMS-PF) and the Cochrane Prognosis Methods Group template for prognosis reviews. Two review authors independently screened the studies, extracted data, assessed the risk of bias according to the Quality in Prognosis Studies (QUIPS) tool, and assessed the certainty of the evidence (GRADE). Meta-analyses were performed by pooling adjusted estimates. When meta-analysis was not possible, we reported the main results narratively.

We included seven studies (726,293 participants), all of which were retrospective cohort studies with participants recruited and managed in hospitals between 2000 and 2018. Studies took place in the USA, Spain, and Japan. Most studies were multicentre. None were conducted in low- or middle-income countries. The participants' mean age ranged from 62 to 69 years, and the proportion of females was higher in six of the seven studies, ranging from 46% to 60%. Sex and gender terms were used inconsistently. Participants received different PE treatments: reperfusion, inferior vena cava filter, anticoagulation, and haemodynamic/respiratory support. The prognostication time (the point from which the outcome was predicted) was frequently omitted. The included studies provided data for three of our outcomes of interest. We did not consider any of the studies to be at an overall low risk of bias for any of the outcomes analysed. We judged the certainty of the evidence as moderate to low due to imprecision and risk of bias. We found moderate-certainty evidence (due to imprecision) that for female patients there is likely a small but clinically important reduction in all-cause mortality at 30 days (odds ratio (OR) 0.81, 95% confidence interval (CI) 0.72 to 0.92; I2 = 0%; absolute risk difference (ARD) 24 fewer deaths in women per 1000 participants, 95% CI 35 to 10 fewer; 2 studies, 17,627 participants). However, the remaining review outcomes do not indicate lower mortality in female patients. There is low-certainty evidence (due to serious risk of bias and imprecision) indicating that for females with PE, there may be a small but clinically important increase in all-cause hospital mortality (OR 1.11, 95% CI 1.00 to 1.22; I2 = 21.7%; 95% prediction interval (PI) 0.76 to 1.61; ARD 13 more deaths in women per 1000 participants, 95% CI 0 to 26 more; 3 studies, 611,210 participants). There is also low-certainty evidence (due to very serious imprecision) indicating that there may be little to no difference between males and females in PE-related mortality at 30 days (OR 1.08, 95% CI 0.55 to 2.12; I2 = 0%; ARD 4 more deaths in women per 1000 participants, 95% CI 22 fewer to 50 more; 2 studies, 3524 participants). No study data was found for the other outcomes, including sex-specific mortality data at one year. Moreover, due to insufficient studies, many of our planned methods were not implemented. In particular, we were unable to conduct assessments of heterogeneity or publication bias or subgroup and sensitivity analyses.

The evidence is uncertain about sex (being male or female) as an independent prognostic factor for predicting mortality in adults with PE. We found that, for female patients with PE, there is likely a small but clinically important reduction in all-cause mortality at 30 days relative to male patients. However, this result should be interpreted cautiously, as the remaining review outcomes do not point to an association between being female and having a lower risk of death. In fact, the evidence in the review also suggested that, in female patients, there may be a small but clinically important increase in all-cause hospital mortality. It also showed that there may be little to no difference in PE-related mortality at 30 days between male and female patients. There is currently no study evidence from longitudinal studies for our other review outcomes. Although the available evidence is conflicting and therefore cannot support a recommendation for or against routinely considering sex to quantify prognosis or to guide personalised therapeutic approaches for patients with PE, this Cochrane review offers information to guide future primary research and systematic reviews.

Nonconsent to pulmonary vascular (or advanced) imaging for suspected pulmonary embolism (PE) in pregnancy can delay diagnosis and treatment, increasing risk of adverse outcomes. We sought to understand factors associated with consent and understand outcomes after nonconsent.

This retrospective cohort study was undertaken across 21 community hospitals from October 1, 2021, through March 31, 2023. We included gravid patients undergoing diagnostics for suspected PE who were recommended advanced imaging. The primary outcome was verbal consent to advanced imaging. Diagnostic settings were nonobstetric (99% emergency departments [EDs]) and obstetrics (labor and delivery and outpatient clinics). Using quasi-Poisson regression, we calculated adjusted relative risks (aRRs) of consenting with 95% confidence intervals (CIs). We also reported symptom resolution and delayed imaging at follow-up and 90-day PE outcomes.

Imaging was recommended for 405 outpatients: median age was 30.5 years; 50% were in the third trimester. Evaluation was more common in nonobstetric (83%) than obstetric settings (17%). Overall, 314 (78%) agreed to imaging and 91 (22%) declined imaging. Consenting was more prevalent in obstetric settings compared with nonobstetric settings: 99% versus 73% (p < 0.001). When adjusted for demographic and clinical variables, including pretest probability, only obstetric setting was independently associated with consenting: aRR 1.26 (95% CI 1.09-1.44). Seventy-nine (87%) patients declining imaging had 30-day follow-up. Eight of 12 who reported persistent or worsening symptoms on follow-up were again recommended advanced imaging and consented. Imaging was negative. None who initially declined imaging were diagnosed with PE or died within 90 days.

One in five gravid patients suspected of PE declined advanced imaging, more commonly in nonobstetric (principally ED) settings than obstetric settings. Patients symptomatic on follow-up responded favorably to subsequent imaging recommendations without 90-day outcomes. Improving the communication and documentation of informed consent and securing close follow-up for nonconsenters may mitigate risks of missed and delayed PE diagnosis.

Venous thromboembolism (VTE), consisting of both deep vein thrombosis (DVT) and pulmonary embolism (PE), is an extremely common condition both in the United States and worldwide. Not only is the diagnosis associated with significant morbidity and mortality for patients but it also imposes a deleterious financial burden on the US healthcare system. Diagnosis may be challenging due to variability in clinical presentation and requires a sequential workup including assessment of clinical pretest probability for VTE, D-dimer testing, and imaging. Following diagnosis, proper risk stratification is necessary to determine the appropriate treatment as well as the need for inpatient care. Elucidation of underlying major or minor risk factors at the time of diagnosis is essential as the presence of which may influence the duration of therapy. First-line treatment for most patients is anticoagulation with a direct oral anticoagulant (DOAC) for a minimum of 3-6 months. In multiple clinical trials, DOACs have proven to be non-inferior to vitamin K antagonists for the treatment of VTE with a lower risk of bleeding. Special consideration should be taken in the choice of agent and duration of treatment for patients who have underlying thrombophilias or malignancy and who are pregnant.

Catheter-related deep venous thrombosis (CR-DVT) is a common complication of central venous catheters, however optimal prophylactic and treatment strategies have yet to be fully defined. While the use of anticoagulation for CR-DVT prophylaxis is not routinely recommended, current available data offer heterogeneous results due to small sample size, non-uniform study design, and varying comorbid conditions. Available guidelines for the treatment of CR-DVT generally recommend a limited duration of anticoagulation after catheter removal. If ongoing use is required and the device remains functional, guidelines support anticoagulation throughout the time the catheter remains in place. It is worth acknowledging that data guiding these recommendations is largely derived from observational studies of upper extremity CR-DVT, along with randomized trials of anticoagulation in patients with lower extremity DVT. Therefore, large, randomized controlled trials are desperately needed to define optimal management, especially in patients who are at high risk for bleeding. This review explores the epidemiology and risk factors of CR-DVT, diagnostic, prophylactic and treatment strategies, guideline recommendations, and future advances in the field, including the introduction of novel anticoagulants. With current available evidence, we also conclude with an individualized approach to preventing and managing CR-DVT to assist clinicians who are faced with this common clinical scenario.

Aneurysms are abnormalities in blood vessels that can be categorized as true aneurysms or pseudoaneurysms. Pseudoaneurysms occur when one or more layers of the blood vessel wall rupture, often as a result of trauma or medical procedures, such as nephrolithotomy. This case study discusses a pseudoaneurysm of the lower pole segmental artery of the kidney that developed after an open nephrolithotomy despite an avascular surgical plan. The patient experienced intermittent gross hematuria, highlighting the potential complications associated with renal surgeries. The diagnosis was challenging, necessitating a high suspicion index and imaging modalities such as ultrasound, CT scans, and angiography. Treatment options varied from conservative management to angioembolization, which is preferred for its minimally invasive nature and ability to preserve renal parenchyma. This study aims to demonstrate that the risk of pseudoaneurysm should be considered even in an atrophic nephrolithotomy performed without vascular invasion.

Pregnancy is a prothrombotic state due to an estrogen-driven shift in the coagulation system, increased venous stasis, and external restriction of blood flow caused by the gravid uterus. Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in pregnancy. Preventing, recognizing, and treating thrombosis in pregnancy, as well as the postpartum period, often challenges decision making in the clinical setting. In early pregnancy, guidance with respects to thrombophilia testing and anticoagulation in increasing the likelihood of live birth among patients with recurrent miscarriages is evolving. This review explores emerging data that support clinical decision making in thrombosis care in women with common thrombotic complications in pregnancy. The first case outlines VTE diagnosis in pregnancy, initial anticoagulation management, management around delivery and postpartum, and subsequent long-term anticoagulation treatment. The second case examines testing for inherited and acquired thrombophilia in the setting of recurrent miscarriage and the management of obstetric antiphospholipid syndrome. Lastly, the third case reviews VTE risk assessment and prevention in pregnancy and the postpartum period, as well as duration and dose of postpartum thromboprophylaxis. Review of these common clinical scenarios surrounding thrombotic complications in pregnancy demonstrates recent advances in high-quality data, current gaps in knowledge, and variation in expert opinion. Ultimately, multidisciplinary discussion and teamwork remain key to optimal, safe care. Clinicians must prioritize collaborative, high-quality trials and prospective clinical management studies to better understand and define best practice in this population.

Venous thromboembolism (VTE) is a leading cause of maternal mortality. The risk of VTE in pregnant and postpartum women is ~ five times higher compared with non-pregnant women. There is a physiological tendency to a hypercoagulable state, from conception to the postpartum period. Several non-obstetric risk factors independently increase the risk of VTE. Since most signs and symptoms of VTE might mimic those of a normal pregnancy, a high index of suspicion is warranted to establish the diagnosis. D-dimer, ultrasonography and computed tomography pulmonary angiography are the primary tools for VTE diagnosis. Management mainly revolves around systemic anticoagulation with heparin. Advanced therapy options exist, but these can be considered for selected high-risk cases.

Antiplatelet drugs are a cornerstone in managing atherosclerotic vascular disease (ASVD). However, their interactions with other medications present significant challenges to treatment efficacy and safety. Patients with ASVD often require multiple treatment regimens due to complex comorbidities, which increases the risk of drug-drug interactions (DDIs). These interactions can lead to drug resistance, reduced therapeutic outcomes, or adverse effects. A thorough understanding of DDIs is crucial for optimizing patient care.

This review aims to explore the clinical significance. mechanisms, and implications of DDIs in antiplatelet therapy Additionally, it seeks to identify future research directions to advance personalized treatment strategies and improve therapeutic outcomes.

A systematic literature review was conducted using key databases, focusing on clinical studies, mechanistic research, and guidelines related to antiplatelet therapy and DDIs. Findings were analyzed to identify common interaction patterns, associated risks, and management strategies.

The review identifies common DDIs involving antiplatelet drugs, particularly with anticoagulants, nonsteroidal anti-inflammatory drugs, and proton pump inhibitors. These interactions primarily occur through pharmacokinetic mechanisms, such as alterations in drug metabolism via cytochrome P450 enzymes, and pharmacodynamic mechanisms, including synergistic or antagonistic effects on platelet inhibition. Clinically, DDIs can increase bleeding risk, reduce antiplatelet efficacy, and contribute to adverse cardiovascular outcomes. Strategies to mitigate these risks include individualized drug selection, dose adjustments, genetic testing, and therapeutic drug monitoring.

Effective management of DDIs in antiplatelet therapy is essential to improve clinical outcomes. A patient-specific approach, considering comorbidities, genetic predispositions, and concurrent medications, is crucial. The review categorizes DDIs based on clinical settings and underscores the need for further research on predictive biomarkers, pharmacogenomics, and advanced monitoring techniques.

DDIs significantly impact the effectiveness and safety of antiplatelet therapy, necessitating a comprehensive understanding of their mechanisms and clinical implications. Future research should focus on developing personalized treatment approaches, integrating genetic testing, and optimizing pharmacological monitoring to minimize risks and improve therapeutic outcomes. This review provides a foundation for advancing clinical practice and enhancing the management of patients with ASVD.

The risk of recurrent venous thromboembolism (VTE) in patients with isolated distal deep vein thrombosis (IDDVT) is generally low, particularly when IDDVT is asymptomatic. However, cancer patients with IDDVT, even asymptomatic IDDVT, may be at a higher risk of recurrent VTE.

To compare the clinical outcomes of cancer patients with asymptomatic and symptomatic IDDVT.

The ONCO DVT trial is a randomized clinical trial that compared 12-month versus 3-month edoxaban treatment regimens in cancer patients with IDDVT. In this post hoc analysis, 601 patients were categorized into the asymptomatic (n = 479) and symptomatic (n = 122) groups based on IDDVT-related symptoms at diagnosis. The primary outcome was the composite of symptomatic recurrent VTE or VTE-related death at 12 months, while the major secondary outcome was major bleeding at 12 months.

The cumulative 12-month incidence of the primary outcome was lower in the asymptomatic group than that in the symptomatic group (2.9% vs 13.4%; P < .001; hazard ratio, 0.21; 95% CI, 0.10-0.47). Among the 12 patients with symptomatic recurrent VTE in the asymptomatic group, 8 (67%) had recurrent IDDVT, and 11 (92%) experienced recurrence after discontinuing anticoagulation therapy. The cumulative 12-month incidence of major bleeding was lower in the asymptomatic group than that in the symptomatic group (7.8% and 13.2%; P = .048).

The risk of recurrent symptomatic VTE was lower in cancer patients with asymptomatic IDDVT than in those with symptomatic IDDVT. Most recurrent VTE events were recurrent IDDVT, with the majority occurring after discontinuing anticoagulation therapy.

Mitral valve repair (MVr) is the gold standard treatment for degenerative mitral regurgitation, yet there is ongoing controversy regarding optimal anti-thrombotic therapy post-MVr. This scoping review aimed to summarise current evidence on the safety and efficacy of anti-thrombotic therapy after MVr, identify knowledge gaps and propose a future study design.

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov, the WHO International Clinical Trials Registry Platform and bibliographies of included trials, guidelines and other reviews from inception to 17 September 2024. Randomised controlled trials (RCT) and cohort and case-control studies assessing any anti-thrombotic therapy with any outcomes after MVr were included. Using a predefined collection form, two authors independently extracted data on study characteristics and results were summarised narratively into themes based on the PICO elements.

Of 1296 screened references, we included 11 studies (10 cohort and one non-inferiority RCT). All studies compared vitamin K antagonist (VKA) to an anti-platelet, direct oral anti-coagulant or no anti-thrombotic therapy for median duration of 90 days. Thromboembolic and bleeding event incidences ranged from 0% to 14.3% and 0% to 9.1%, respectively. Seven studies reported no difference in thromboembolic events, and three reported reduced rates with VKA compared with control, while results for bleeding events varied widely. The RCT found edoxaban was non-inferior to warfarin for thromboembolic outcomes, but not for bleeding. Substantial methodological and clinical heterogeneity, high risk of bias and insufficient mitigation of confounders, such as concomitant atrial fibrillation, were prevalent across studies.

Based on this scoping review, existing literature on anti-thrombotic therapy after MVr is inconclusive due to design limitations. We proposed a study design for a pragmatic RCT that addresses prior study limitations and that could provide definitive evidence to guide anti-thrombotic management in MVr patients.

Catheter-related right atrial thrombus (CRAT) is a severe complication in hemodialysis patients that can lead to catheter dysfunction and pulmonary embolism (PE). However, no standardized treatment strategy currently exists for hemodialysis-related CRAT. This study aims to investigate the efficacy of catheter replacement and antiplatelet therapy in managing hemodialysis CRAT.

We conducted a retrospective cohort study on patients at West China Hospital diagnosed with catheter dysfunction caused by right atrial thrombosis between May 2019 and March 2022. All CRAT were asymptomatic and underwent catheter replacement (either guidewire exchange or insertion at a new site), with the new catheter tip repositioned away from the original location and closer to the right atrium. Antiplatelet therapy with dipyridamole was initiated post-procedure. We analyzed the efficacy of catheter replacements and antiplatelet therapy in hemodialysis-related CRAT.

Among the 178 patients with CRAT who underwent catheter replacement, the success rate was 98.9%. Preoperative examinations detected asymptomatic PE in 10 patients (5.6%). During follow-up, 3 patients (1.9%) developed new asymptomatic PE post-operation, and no fatal PE occurred. The catheter primary patency rates at 3, 6, and 12 months were 87.0%, 62.6%, and 36.7%, respectively. The secondary patency rates were 91.7%, 75.7%, and 52.3% at 3, 6, and 12 months, respectively. No patients died due to PE or other thrombotic complications.

Catheter replacement combined with antiplatelet therapy may be a potential treatment approach for patients with hemodialysis-related CRAT < 6 cm, without other complications except from catheter dysfunction.

Despite guideline recommendations to use low-molecular-weight heparins (LMWHs) or direct oral anticoagulants in the treatment of most patients with acute pulmonary embolism (PE), US-based studies have found increasing use of unfractionated heparin (UFH) in hospitalized patients.

To identify barriers and facilitators of guideline-concordant anticoagulation in patients hospitalized with acute PE.

This qualitative study conducted semistructured interviews from February 1 to June 3, 2024, that were recorded, transcribed, and analyzed in an iterative process using reflexive thematic analysis. Interview participants were physicians in emergency medicine, hospital medicine (hospitalist), interventional cardiology, and interventional radiology. Participants were recruited using maximum variation sampling targeting UFH-dominant vs LMWH-dominant approaches in hospitalized patients with acute PE. We triangulated results with a group of interventional cardiologists and radiologists (interventionalists).

Common themes and factors associated with anticoagulant selection for hospitalized patients with acute PE. Reflexive thematic analysis was used to identify these themes and factors.

Of the 46 interviewees (median [IQR] age, 43 [36-50] years; 33 who identified as men [71.7%]), 25 (54.3%) were emergency physicians, 17 (37.0%) were hospitalists, and 4 (8.7%) were interventionalists. Each interview lasted a median (IQR) of 29 (25-32) minutes. Prominent themes associated with anticoagulant selection included agnosticism regarding choice of anticoagulant, the inertia of learned practice, and therapeutic momentum after anticoagulation initiation. Institutional culture and support were factors associated with choice of the dominant anticoagulation strategy. Additionally, factors associated with UFH use were fear of decompensation and misperceptions regarding the pharmacology of anticoagulants and catheter-directed treatments.

In this qualitative study, physicians across a spectrum of specialties and geographical settings reported common barriers and facilitators to the use of guideline-concordant anticoagulation in patients hospitalized with acute PE, particularly agnosticism regarding choice of anticoagulant, inertia of learned practice, therapeutic momentum after anticoagulation initiation, and institutional culture and support. Future implementation efforts may consider targeting these domains.

Society recommendations for preemptive (or empiric) anticoagulation during antenatal pulmonary embolism (PE) diagnostics rely on expert opinion, which varies widely across guidelines. The American College of Chest Physicians (CHEST), for example, recommends preemptive anticoagulation when PE is highly suspected or when a delay in imaging is anticipated. The American College of Obstetricians and Gynecologists, however, makes no mention of preemptive anticoagulation for suspected PE in their practice bulletin on thromboembolism in pregnancy. Patterns of preemptive anticoagulation in pregnancy are unknown.

To describe the prevalence of and CHEST-based eligibility for preemptive anticoagulation in pregnancy.

This retrospective cohort study was undertaken across 21 United States community hospitals from October 1, 2021 through March 30, 2023. We included pregnant adults without COVID-19 undergoing definitive diagnostic PE imaging. We used pregnancy-adapted Geneva scores to calculate pretest probability as a proxy for suspicion.

We included 326 patients: median age, 31.0 years; 51% were in the third trimester. Diagnostic settings included emergency departments (n = 254; 78%), Labor & Delivery (n = 65; 20%), and outpatient clinics (n = 7; 2%). Median time from emergency department computed tomography order to results was 1.40 hours (IQR: 0.78, 2.06). Prevalence of confirmed or presumed PE was low (n = 8; 2.5%). Only 2 patients (0.6%) received preemptive anticoagulation, whereas by CHEST criteria, 34 patients (10.4%) were eligible.

We found rare use of preemptive anticoagulation during antenatal PE diagnostics in this imaged cohort with low PE prevalence and rapid access to diagnostic imaging. More research is needed to explore setting-specific variation in preemptive anticoagulation use.

Acute pulmonary embolism (PE), particularly massive PE, presents significant mortality risk, often necessitating emergency intervention such as surgical embolectomy. The prognosis for patients undergoing such interventions, especially after cardiac arrest, remains poor due to hemodynamic complications. This study aims to evaluate the efficacy of salvage pulmonary embolectomy in patients experiencing cardiac arrest due to massive PE, focusing on survival outcomes and influential risk factors.

Conducted at a single center over 10 years, this retrospective study involved 21 patients who underwent surgical embolectomy post-cardiac arrest due to massive PE. Data were collected on patient demographics, clinical presentation, and outcomes, analyzing factors such as age, hospital stay, and operative details.

Out of 21 patients, 13 survived 1 year post-operation, translating to a 1-year survival rate of 61.90%. Intra-hospital survival was 76.19% (16 patients). Notable findings included a significant association between increased age and higher mortality (hazard ratio = 1.14, P = 0.024), and a longer hospital stay post-procedure in non-survivors (hazard ratio = 1.52, P = 0.03).

Salvage pulmonary embolectomy can improve survival in patients with massive PE following cardiac arrest. However, outcomes heavily depend on the patient's age and the length of the hospital stay. Future studies should focus on refining surgical techniques and improving pre- and postoperative care to enhance survival rates further.

We report a case of successful management of a massive pulmonary embolism (PE) with simultaneous hepatic arterial injury using anticoagulation and interventional radiology (IVR). The patient, with pre-existing muscle atrophy, decreased lower extremity mobility, and spinal stenosis, developed bilateral PE during rehabilitation. Following cardiopulmonary arrest, chest compressions for resuscitation resulted in hepatic hemorrhage. The patient was treated with intravenous heparin, transcatheter arterial embolization, thrombectomy, and blood transfusion, leading to full recovery without neurological complications. This case highlights the importance of assessing PE risk in hospitalized patients and highlights the efficacy of IVR in complex cases. J. Med. Invest. 72 : 177-181, February, 2025.