Fondaparinux for the Treatment of Superficial-Vein Thrombosis in the Legs — NEJM
A 42 year-old male former semi-professional soccer player sustained a right lower extremity popliteal contusion during a soccer game. He was clinically diagnosed with Studie Thrombophlebitis possible traumatic deep vein thrombosis DVTand sent for confirmatory tests.
A duplex doppler ultrasound was positive for DVT, Studie Thrombophlebitis, and the patient was admitted to hospital for anticoagulation unfractionated heparin, warfarin.
Upon discharge from hospital the patient continued oral warfarin anticoagulation six monthsand the use of compression stockings nine months, Studie Thrombophlebitis. He followed Studie Thrombophlebitis with his family doctor at regular intervals for serial coagulation measurements, and ultrasound examinations.
The patient's only identified major thrombotic risk factor was the traumatic injury. One year after the initial deep vein thrombosis DVT the patient returned to contact sport, Studie Thrombophlebitis, however Studie Thrombophlebitis continued to have intermittent symptoms of right lower leg pain and right knee effusion.
Athletes can develop vascular injuries in a variety Studie Thrombophlebitis contact and non-contact sports. Trauma is one of the most common causes of lower extremity deep vein thrombosis DVThowever athletic injuries involving lower extremity traumatic DVT are seldom reported. This diagnosis and the Studie Thrombophlebitis risk factors must be considered during the initial physical examination, Studie Thrombophlebitis.
The primary method of radiological diagnosis of lower extremity DVT is a complete bilateral duplex sonography, which can be augmented by other methods such as evidence-based risk factor analysis. Antithrombotic medication is the current standard of treatment for DVT. Acute thrombolytic treatment Studie Thrombophlebitis demonstrated an improved therapeutic efficacy, and a decrease in post-DVT symptoms. There is a lack of scientific literature concerning the return to sport protocol following a DVT event.
Studie Thrombophlebitis individuals who desire to return to sport after a DVT need to be fully informed about their treatment and risk of reoccurrence, so that appropriate decisions can be made. Athletes are susceptible to a variety of vascular injuries, secondary to either repetitive motion, or high-speed collisions [ 1 ]. The differential diagnosis for lower extremity trauma in sport seldom invites a diagnosis of vascular injury, such as a deep vein thrombosis DVT, Studie Thrombophlebitis.
Failure of the physician to recognize a vascular injury can have catastrophic limb or life threatening pulmonary embolism implications. The epidemiology, diagnosis, treatment, Studie Thrombophlebitis, and recurrence of DVT, Studie Thrombophlebitis, as well as the prevention of post-thrombotic symptoms are the most current areas of clinical research.
Research-based guidelines concerning an athlete's return to sport after a DVT is an important area for future investigation. A 42 year old Polish born male former semi-professional soccer player was seen on May 16 thin the emergency department, with the chief complaint of right leg pain.
The patient had been playing soccer 10 days prior to this visit, and recalled a traumatic "tackle" injury to the posterior area of his right lower extremity, Studie Thrombophlebitis.
He denied experiencing any sensation of tearing or popping in the right knee during the index trauma, and was able to complete the game with only minor discomfort. On day 3 post-injury the patient noted severe pain in his knee and calf with ambulation. The patient visited his primary doctor on post-injury day 8 and was diagnosed with a right lower extremity soft tissue injury.
A right lower extremity Studie Thrombophlebitis ultrasound USand a semi-quantitative D-dimer automated latex procedure were ordered to rule out a vascular disorder. The D-dimer result was also positive for a suspected thrombosis 1. The patient was instructed by his physician to proceed immediately to the emergency department for further evaluation and treatment. The past medical and family history of the patient was non-contributory for a history of thrombophilia or other thrombotic major risk factors.
The patient had a remote 11 years old surgical history of a right-sided inguinal hernia that could have created scar tissue contributing to vascular obstruction and stasis.
The initial emergency department examination demonstrated an exquisitely tender right calf with a 3 cm difference in mid-calf girth 10 cm, Studie Thrombophlebitis. A repeat US investigation confirmed the results of the previous Studie Thrombophlebitis results. The patient was anticoagulated simultaneously with unfractionated heparin and Warfarin sulfate.
A multiview plain film x-ray examination of the right lower extremity demonstrated no Studie Thrombophlebitis, dislocation, or bony mass. A magnetic resonance image MRI of the right knee was done several days after admission, to verify a torn right knee meniscal cartilage that had been previously diagnosed.
The official MRI radiological report included a small free-edge tear of the posterior horn root junction of the lateral meniscus, chondromalasia lateral patella and lateral femoral articular cartilageand a moderate joint effusion Studie Thrombophlebitis a bursal cyst or dilated semimembranous-gastronemius bursa. Anticoagulation was achieved on day 6 of the patient's hospitalization, Studie Thrombophlebitis.
He was discharged on 5 mg of warfarin per day, Studie Thrombophlebitis, with instructions to continue the use of compression stockings. The patient was also advised to follow up with his primary physician for regular monitoring, and to avoid contact or collision activities during anticoagulation, Studie Thrombophlebitis.
The patient was maintained on warfarin for six months, with weekly physician monitoring symptoms, PT, Studie Thrombophlebitis, INR for the first three months post-injury. The monitoring interval was changed to once per month for the remainder of the treatment period.
There were no contributory thrombophilic factors found in these investigations. US examinations after the hospitalization period failed to demonstrate a recurrence or new onset of DVT, however residual echogenic material characteristic of a chronic thrombus was demonstrated in the popliteal vein. Compression stocking use was maintained after hospital discharge, and was discontinued after nine months.
The patient returned to soccer after anticoagulation, with a full understanding of his increased risk of DVT recurrence, Studie Thrombophlebitis. One-year post injury the patient Studie Thrombophlebitis to suffer from intermittent Studie Thrombophlebitis lower extremity discomfort and swelling often unrelated to activity.
An elective arthroscopy was recently performed on the patient's right knee to investigate his long-standing meniscal disruption and effusion.
The arthroscopy demonstrated several areas of arthrosis patellar lateral and medial facets, lateral and medial femoral condylesStudie Thrombophlebitis, and a torn lateral meniscus, Studie Thrombophlebitis. Appropriate partial lateral menisectomy and debridement, Studie Thrombophlebitis, and chondroplasty of the areas of arthrosis were preformed.
An arthroscopic examination of the posterior compartment demonstrated a small cleft-like area just medial to the semimembranosis where the Baker's cyst likely originated. The patient returned to the orthopedist one week post-op with a large cc's hemarthrosis that was aspirated from the knee. He was Studie Thrombophlebitis to follow-up in one month for re-evaluation.
This case study illustrates the importance of considering deep vein thrombosis in the diagnosis of sport-related extremity trauma. Studie Thrombophlebitis is classically related to venous stasis, intimal injury, and coagulation diathesis Virchow's triad. The estimated incidence of DVT from all causes is 0.
Standard risk factors for DVT Studie Thrombophlebitis immobilization, Studie Thrombophlebitis, recent surgery particularly orthopedicmalignancy, Studie Thrombophlebitis, older age, smoking, Studie Thrombophlebitis, coagulation deficits or hypercoagulable states, connective tissue disorders, sex steroid administration, severe dehydration, and major trauma.
These factors include inherited conditions e. Coagulation diathesis through Studie Thrombophlebitis or acquired thrombophilia may promote coagulation [ 3 ]. Coagulation deficits in previously healthy athletes are becoming increasingly identified through laboratory tests, and must be considered as contributing factors for DVTs [ 4 — 7 ]. These authors proposed that countermeasures e.
The testing for hypercoagulable states in an individual after a single episode of thrombosis is a costly, yet routine procedure in many centers. Studie Thrombophlebitis common assumption that an identified presence of a thrombophilic abnormality increases the risk of recurrence, and justifies prolonged therapy is without clear supportive evidence. A review of the current literature concerning the Studie Thrombophlebitis of individuals Studie Thrombophlebitis coagulation deficits concludes that there is no clear evidence that modifying treatment because of an identified hypercoaguable state alters the outcome, or that more intensive therapy is required in patients with laboratory evidence of thrombophillia [ 3 ], Studie Thrombophlebitis.
Exercise is thought to act as a protective mechanism against thrombosis, due to the controlled balance between the exercise activated coagulation and fibrinolytic pathways [ 8 ], Studie Thrombophlebitis.
This type of thrombosis has been documented in a variety of sports as effort thrombosis or "Paget-Schroetter's syndrome" [ 9 — 14 ], Studie Thrombophlebitis. This syndrome is been described as a primary thrombosis of the subclavicular and axillary veins, usually proceeded by a strenuous effort or repetitive action involving retroversion and hyperabuction of the extremity [ 10 ].
Vascular compression by adjoining bone, ligament and muscle or resulting intimal traumas have been documented as contributing factors toward the development of upper and lower extremity thrombosis [ 15 — 27 ].
Lower extremity DVT with a Studie Thrombophlebitis sporting injury in otherwise healthy active adults is seldom mentioned in the medical literature [ 16 — 29 ], Studie Thrombophlebitis.
This lack of reported cases of this type of thrombosis may be due to either underreporting or incorrect diagnosis. Very few cases of sport-related lower extremity DVT involved direct externally trauma [ 2930 ].
There is one case report Finnish language that specifically related DVT development to soccer-related trauma [ Studie Thrombophlebitis ], and one case report of lower extremity DVT in a soccer player with coagulation deficiencies [ 31 ]. There is also one case Studie Thrombophlebitis in the literature of a traumatic popliteal thrombosis in a hockey player, which resulted in a fatal pulmonary embolism PE [ 29 ].
The popliteal, posterior tibial and peroneal veins are susceptible to intimal trauma by the sudden hyperextension and torsion that the lower extremity experiences in a soccer "kick" or "tackle" motion. The popliteal arteries Studie Thrombophlebitis veins are susceptible to direct, sheering, and muscular compressive forces due to their anatomical position, especially with rapid knee hyperextension or anterior dislocation [ 1322 ].
The literature demonstrates the importance and efficacy of a complete bilateral duplex Studie Thrombophlebitis as the Studie Thrombophlebitis method of DVT diagnostic investigation [ 32 ]. US findings can be augmented by other methods Studie Thrombophlebitis. A review of the current literature also suggests the need for comprehensive evidence-based guidelines concerning the use of wie Lungenembolie zu heilen diagnostic investigations of suspected DVT [ 35 ].
Anticoagulation is effective in preventing DVT propagation and PE, but has no chemical fibrinolytic activity, Studie Thrombophlebitis.
This type of therapy allows for intrinsic fibrinolysis to occur. Intrinsic fibrinolysis that occurs slowly does not preserve the function of the venous valves, which become fibrotic and fixed after a few weeks of being trapped in clot [ 36 ]. The symptoms experienced by individuals without complete clot resolution include heavy or achy legs, edema, throbbing paresthesia, Studie Thrombophlebitis, purities, numbness, stiffness, and difficulty standing or ambulating, Studie Thrombophlebitis.
Postthrombotic syndrome PTS Studie Thrombophlebitis characterized by brawny edema of the leg, stasis dermatitis, hyperpigmentation, induration, ulceration and chronic leg pain.
Four level DVT, calf vein thrombosis, recurrence of ipsilateral DVT, and a non-sufficient oral anticoagulation are of prognostic significance for developing clinically relevant symptoms within 10 to 20 years after the first DVT [ 37 ]. There is growing evidence that the early lysis provided by thrombolytic therapy is more likely to preserve valve function, decreasing the likelihood of DVT recurrence, and the occurrence of PTS [ 3839 ]. Recent trials of new antithrombotic agent used Studie Thrombophlebitis endpoint of 'symptomatic recurrent DVT', which was defined as the combination of persistent or recurrent symptoms along with the radiographic evidence Studie Thrombophlebitis primary clot progression Studie Thrombophlebitis new thrombus formation.
The general knowledge concerning quality of life and burden of illness in patients with persistent post-DVT symptoms is limited, Studie Thrombophlebitis. This issue is especially important to the athletic patient, as participation in sport is usually an extremely important component of quality of life.
For routine monitoring of outcomes in chronic venous disorders there are questionnaires that are available [ 40Studie Thrombophlebitis, 41 ], Studie Thrombophlebitis.
The athlete's primary concern upon the initial DVT diagnosis is return to play. The issue of return to sport after a lower extremity DVTs has only been addressed only once in the literature concerning return to non-contact sport [ 43 ].
General guidelines for sedentary individuals allow for a gradual return to return to daily activities over a six week period [ 43 ], with no contact activities allowed during the period of anticoagulation, Studie Thrombophlebitis.
Roberts and Christie [ 43 ] provided a theoretical framework, based on the natural history of animal models for the Studie Thrombophlebitis and expeditious return of the athlete. These authors suggested a protocol that combines a graduated return to activity and anticoagulation therapy with regular physician based reevaluation [ 43 ].
An athlete who wants to return to a contact or collision sport should be informed of the possible increased risk of recurrent DVT that he or she may face, Studie Thrombophlebitis, above the current estimates derived from the general population. There is no current evidence in the literature that investigates the specific risk factor of a traumatic collision, and the recurrence of a DVT. This lack of evidence suggests that the patient and physician should work together to make an informed return to play decision involving the patient's current individual risk profile, the likelihood of DVT recurrence, athletic goals, and the perceived importance of the particular sport to quality of life.
The authors would like to acknowledge the contribution Jefferey E. This article is published under license to BioMed Central Ltd. This is an open-access article Studie Thrombophlebitis under the terms of the Creative Commons Attribution License http:
The risk of venous thrombosis is approximately 2- to 4-fold increased after air travel, but Studie Thrombophlebitis absolute risk is unknown. The objective of this study was to assess the absolute risk of venous thrombosis after air travel. We conducted a cohort study among employees of large international companies and organisations, Studie Thrombophlebitis, who were followed between 1 January and 31 December The occurrence of symptomatic venous thrombosis was linked to exposure to air travel, as assessed by travel records provided by the companies and organisations.
A long-haul flight was defined as a flight of at Studie Thrombophlebitis 4 h and participants were considered exposed for a postflight period of 8 wk. A total of 8, employees were followed during a total follow-up time of 38, person-years Studie Thrombophlebitis. The total time employees were exposed to a long-haul flight was 6, PY. In the follow-up period, 53 thromboses Studie Thrombophlebitis, 22 of which within 8 wk of a long-haul flight, yielding an incidence rate of 3.
This rate was equivalent to a risk of one event per 4, long-haul flights. The risk increased with exposure to more flights within a short time frame and with Studie Thrombophlebitis duration of flights, Studie Thrombophlebitis. The incidence Studie Thrombophlebitis highest in the Studie Thrombophlebitis 2 wk after travel and gradually decreased to baseline after 8 wk.
The risk was particularly high in employees under age 30 y, women who used oral contraceptives, and individuals who were particularly short, tall, Studie Thrombophlebitis, or overweight. The risk of symptomatic venous Studie Thrombophlebitis after air travel is moderately increased on average, Studie Thrombophlebitis, and rises with increasing exposure and in high-risk groups.
June 28, ; Accepted: August 20, ; Published: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors have declared that no competing interests exist. Blood normally flows smoothly throughout the human body, supplying the brain and other vital organs with oxygen and nutrients. When an injury occurs, proteins called clotting factors make the blood gel or coagulate at the injury site. The resultant blood clot thrombus plugs the wound and prevents blood loss.
Sometimes, however, a thrombus forms inside an uninjured blood vessel and partly or completely blocks the blood flow. A clot inside one of the veins vessels that take blood to the heart deep within the body is called a deep vein thrombosis DVT.
Symptoms of DVT which usually occurs in the deep veins of the leg include pain, Studie Thrombophlebitis, swelling, and redness in one leg. DVT is usually treated with heparin and warfarin, two anticoagulant drugs that stop the blood clot growing.
If left untreated, part of the clot an embolus can break off and travel to the lungs, where it can cause a Studie Thrombophlebitis condition called pulmonary embolism PE, Studie Thrombophlebitis. Fortunately, DVT and PE Studie Thrombophlebitis rare but having an inherited blood clotting disorder, taking an oral contraceptive, and some types of surgery are all risk factors for them.
In addition, long-haul plane travel increases the risk of DVT and PE, known collectively as venous thrombosis VT 2- to 4-fold, Studie Thrombophlebitis, in part because the enforced immobilization during flights slows down blood flow. Although the link between air travel and VT was first noticed in the s, exactly how many people will develop DVT and PE the absolute risk of developing VT after a long flight remains unknown.
This information is needed so that travelers can be given advice about their actual risk and can make informed decisions about trying Studie Thrombophlebitis reduce that Studie Thrombophlebitis by, for example, taking small doses of anticoagulant medicine before a flight.
In this study, the researchers have determined the absolute risk of VT during and after long-haul air travel in a large group of business travelers. The researchers enrolled almost 9, employees from several international companies and organizations and followed them for an average of 4. The details of flights taken by each employee were obtained from company records, and employees completed a Web-based questionnaire about whether they Studie Thrombophlebitis developed VT and what risk factors they had for the condition.
Out of 53 thrombi that occurred during the study, 22 occurred within eight weeks of a long-haul flight a flight of more than four hours. From this and data on the total time employees spent on long-haul flights, the researchers Studie Thrombophlebitis that these flights tripled the risk of developing VT, and that the absolute risk Antonovka von Krampfadern probability of something occurring in a certain time period of a VT occurring shortly after such travel was one event per 4, Studie Thrombophlebitis, flights.
Studie Thrombophlebitis also calculated that the risk of VT was increased by exposure to more flights during a short period and to longer flights and was greatest in the first two weeks after a flight. In addition, the risk of VT was particularly high in young employees, women taking oral contraceptives, and people who were short, Studie Thrombophlebitis, tall or overweight. The main finding of this study is that the absolute risk of VT after of a long-haul flight is low—only one passenger out of nearly 5, is likely to develop VT because of flying.
However, the study included only healthy people without previous VT whose average age was 40 years, so the absolute risk of VT after long-haul flights might be higher in the general traveling population.
Even so, this finding strongly suggests that prophylactic preventative use of anticoagulants by all long-haul travelers may not be justified because these drugs have potentially dangerous side effects for example, they can cause uncontrolled bleeding. Subgroups of travelers with additional risk factors for VT might, however, benefit from the use of this and other prophylactic measures, but randomized trials are needed to find out who would benefit most from which prophylactic measure.
Please access these Web sites via the online version of this summary at http: InJacques Louvel reported four cases of venous thrombosis following air travel [ 1 ]. More recently, several investigators have shown an association between air travel and venous thrombosis, with a 2- to 4-fold increased risk in most studies [ 2 — 8 ].
Two follow-up studies demonstrated a dose—response relationship between the occurrence of pulmonary embolism shortly after arrival at the airport and the distance travelled [ 910 ]. Still, the most relevant element, Studie Thrombophlebitis. Hence, the absolute risk of symptomatic venous thrombosis after long-haul travel must lie between these extremes. Knowledge of the absolute risk of symptomatic thrombosis after air travel is needed to provide travellers with solid advice regarding their actual risk and to evaluate the utility of prophylactic measures.
Since two billion passengers fly annually data [ 15 ]even a small increase in risk will have a major impact on the number of events.
Overestimation of Studie Thrombophlebitis risk may lead to inappropriate use of potentially dangerous antithrombotic drugs [ 1617 ]. In addition to estimating the absolute risk of symptomatic deep vein thrombosis or pulmonary embolism after long haul air travel, we assessed Studie Thrombophlebitis effects of exposure to several flights within a short time frame, duration of travel, and the occurrence of venous thrombosis in relation to the time passed after air travel.
Finally, Studie Thrombophlebitis, we determined the effect of air travel within high-risk groups. We performed a cohort study among employees of large international companies and organisations. During the follow-up period, Studie Thrombophlebitis, thrombotic events were linked to exposure to air travel.
All organisations and companies had a central database with records of employees' business travel. Start of follow-up varied per company, between 1 January and 1 January or at start of the employment if later, Studie Thrombophlebitis. Follow-up ended between 1 December and 1 Januarywhen venous thrombosis was diagnosed or at the end of employment, whichever occurred first, Studie Thrombophlebitis, with approximately 5 y of follow-up per company.
We developed Web-based questionnaires, using Apian Survey Pro 3. These contained questions about venous thrombosis occurrence at any time Studie Thrombophlebitis in the follow-up period and risk factors for venous thrombosis, Studie Thrombophlebitis. Employees were invited to take part by a personal e-mail containing a link to the questionnaire and a unique password, which ensured that each individual could enter only once, Studie Thrombophlebitis. With intervals of a few weeks, nonresponding employees received two or three reminders, Studie Thrombophlebitis.
The questionnaire can be viewed at http: Date of travel and duration of travel not including stopover time were taken from the organisations' travel database, Studie Thrombophlebitis. Participants who reported venous thrombosis were asked to fill in a consent form for medical chart review.
Only symptomatic first venous thrombotic events that were diagnosed with objective methods were considered. Deep vein thrombosis had to be diagnosed by compression ultrasonography or venography. Pulmonary embolism had to be diagnosed by spiral CT scanning, high-probability ventilation-perfusion scanning, or angiography.
Superficial thrombophlebitis was not included, Studie Thrombophlebitis. For the analysis of the overall effect of flying, exposure time was Studie Thrombophlebitis as a time window of 8 wk after a long-haul flight flight of at least 4 h.
For each individual, the total time exposed and not exposed was calculated. The incidence rate IR of venous thrombosis within 8 wk of a long-haul flight was calculated by dividing the number of cases that occurred in this exposure window by the number of exposed person-years PY.
The IR of venous thrombosis without exposure was calculated in the same way events over person-time outside exposure windows. The incidence rate ratio IRR adjusted for age and sex was calculated using Poisson regression analysis. The overall effect of flying was assessed for the whole group of employees and separately for subgroups based on sex, age, oral contraceptive use, body mass index BMIand height.
The Studie Thrombophlebitis of person-years exposed and unexposed to oral contraceptive use was calculated for women younger than 50 y. In addition, we calculated the absolute risk of venous thrombosis Studie Thrombophlebitis flight by dividing the number of cases that occurred within 8 wk of a long-haul flight by the total number of flights longer than 4 h made by all responding employees.
Employees were often exposed to more than one flight in the 8 wk exposure windows, so time windows were frequently overlapping.
To assess the effect of number of flights, the total time employees were exposed to one to five flights or more Studie Thrombophlebitis calculated. Furthermore, we calculated the increase in risk for each extra flight using Poisson regression, Studie Thrombophlebitis.
An employee makes one flight of 6 h on day 1 and another flight of 11 h on day A Per number of flights: Exposure from day 10 to 56, is two flights; from day 56 to 66, one flight. B Per category of duration: C Per time window.
From day 1 to 10, the employee is exposed to the time window of 0—2 wk due to the first flight. From day 24 to 38, the employee is exposed to the time window of 2—4 wk, from day 38 to 66 the time window of Prüfung trophischen Geschwüren wk and, finally, Studie Thrombophlebitis, from day 66 to 94 the time window of 8—12 wk.
To assess the effect of duration of travel, we calculated IRs and IRRs within 8 wk of flights of varying duration, Studie Thrombophlebitis, i. If time windows were overlapping, only the duration of the longest flight was considered for this analysis Figure 1 B. The absolute risk per flight for each category of duration was calculated by dividing the number of cases that occurred within 8 wk Studie Thrombophlebitis a flight by the total number of flights in the corresponding category.
Furthermore, Studie Thrombophlebitis, we calculated the increase in risk for each extra hour of duration of a flight using Poisson regression. The occurrence of venous thrombosis in relation to the period of time that had passed after travelling was assessed by calculating IRs and IRRs for periods of 0—2 wk, 2—4 wk, 4—8 wk, and 8—12 wk after a flight of at least 4 h. The period of 12 wk after a flight was split into these four time windows, creating mutually exclusive exposure windows.
If a person was exposed to several Studie Thrombophlebitis and hence to more than one time window, the overlapping time was counted only in the time window closest to the Studie Thrombophlebitis Figure 1 C. General characteristics of the study population are shown in Table 1. The total follow-up time of participating employees was 38, PY, with a mean follow-up per participant of 4, Studie Thrombophlebitis. Flight data are shown in Table 1.
The 8, responders had madeflights during follow-up, and 6, individuals had travelled by air at least once. The mean number of long-haul flights per person per year was 2. In total, 76 employees reported that they had suffered from venous thrombosis in the follow-up period.
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