Search Results (42)

Background: Inflammatory bowel disease (IBD) is a chronic inflammatory disorder that confers an increased risk of venous thromboembolism (VTE) and subsequent pulmonary embolism (PE). The risk stems from chronic systemic inflammation promoting endothelial dysfunction and hypercoagulability. Data on specific inpatient outcomes and procedural needs in patients with IBD with acute PE remains limited. This study explores these outcomes at a national level. Methods: We conducted a Nationwide Inpatient Sample (NIS) database analysis (2016–2020). Adult hospitalizations for acute PE were identified using ICD-10-CM codes and stratified based on IBD status. Multivariable regression analysis was performed to determine independent associations between IBD status and in-hospital mortality, length of stay (LOS), cardiac complications, and ICU-level interventions (intubation, central venous catheterization (CVC), arterial line placement, requirement of vasopressors), and blood transfusion. Results: Among 377,143 acute PE hospitalizations, 4123 (1.1%) had IBD. Patients with IBD were younger (58.72 vs. 62.78 years, p < 0.001) and had lower prevalence of diabetes mellitus, hypertension, end-stage renal disease (ESRD), dyslipidemia, overweight/obesity, coronary artery disease and smoking status (p < 0.05). Despite a favorable baseline profile, patients with IBD had a longer length of stay (LOS) (8.82 vs. 7.30 days, p < 0.001) but no significant association with in-hospital mortality (aOR = 0.93, p = 0.281). Multivariable analysis showed patients with IBD had higher odds of requiring CVC placement (OR = 1.42, p < 0.001), vasopressors (OR = 1.22, p = 0.05), and blood transfusions (OR = 1.78, p < 0.001). Conversely, they had lower odds of cardiac arrest (OR = 0.64, p < 0.001) and cor pulmonale (OR = 0.32, p = 0.012). Conclusions: patients with IBD with acute PE represent a complex population with high resource utilization. Future research is needed the development of IBD-specific PE risk stratification, targeted management, prophylactic and therapeutic anticoagulation guidelines. Full article

Venothromboembolic (VTE) events are considered rare complications following foot and ankle surgery. Most instances of VTE following surgical procedures occur in particularly high-risk patient populations; therefore, VTE prophylactic anticoagulation is initiated based on risk/benefit stratification for each individual patient undergoing foot and ankle surgery. We present a case report on a 40-year-old male who underwent isolated Lisfranc ligament repair and subsequently developed an acute saddle pulmonary embolism and deep vein thrombosis 1 month postoperatively. The patient was on prophylactic Lovenox, yet still developed a life-threatening complication. The patient was found to be on a selective estrogen receptor modulator for the off-label treatment of male infertility. This medication, surgical intervention, and a period of non-weight bearing are believed to be contributory to the patient’s relatively increased hypercoagulable state. This case depicts a rare complication of foot and ankle surgery and highlights the importance of VTE prophylaxis during the postoperative period. Full article

Patients with lower limb paralysis following acute ischemic stroke (AIS) are at a markedly increased risk of deep vein thrombosis (DVT), which may lead to pulmonary embolism and substantially higher mortality and disability. This review comprehensively reviews studies from the past decade on the epidemiology, pathophysiology, and prevention of DVT in AIS patients with lower limb paralysis. The pathogenesis of DVT in this population is multifactorial, involving venous stasis due to immobility, stroke-induced hypercoagulability, endothelial dysfunction, neutrophil extracellular trap-mediated immunothrombosis, and autonomic dysregulation. Effective prevention requires individualized risk stratification, integrating clinical assessment, biomarkers, and imaging tools. Current prophylactic strategies include pharmacological anticoagulation (primarily low-molecular-weight heparin), mechanical interventions (such as intermittent pneumatic compression), and early mobilization and rehabilitation. While combined approaches have demonstrated significant benefits, challenges remain regarding the timing of anticoagulation, balancing bleeding risks, extended thromboprophylaxis, and novel immunothrombosis targets. Future research should focus on personalized prevention protocols, the application of artificial intelligence-based predictive models, and innovative therapies targeting endothelial injury and immune-mediated thrombosis, aiming to improve thromboprophylaxis and overall outcomes in this high-risk population. Full article

Excessive right heart load imposes an acute or chronic injury on the right ventricle (RV), predisposing critically ill neonates and cardiac surgical patients to RV failure, low cardiac output syndrome, and death. Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator that improves ventilation–perfusion matching and unloads the RV without systemic hypotension; nonetheless, its application beyond established neonatal indications remains contentious. Our review synthesizes current mechanistic, translational, and clinical evidence regarding iNO use in three major settings characterized by excessive RV load: (1) neonatal pulmonary hypertension, particularly PPHN; (2) acute and chronic RV overload in older children and adults, including secondary pulmonary hypertension, acute respiratory distress syndrome (ARDS), and acute pulmonary embolism; and (3) perioperative and post-cardiopulmonary bypass (CPB) management in congenital and adult cardiac surgery. In term and near-term infants with hypoxic respiratory failure, pivotal randomized trials show that iNO consistently improves oxygenation and reduces extracorporeal membrane oxygenation (ECMO) use, but this has little effect on survival and long-term neurodevelopment. In ARDS and other adult critical-care indications, iNO provides transient improvements in gas exchange and RV performance without reducing mortality or ventilator duration, and meta-analyses signal an increased risk of acute kidney injury, particularly with prolonged use. In contrast, perioperative studies around CPB demonstrate that prophylactic postoperative iNO and intra-CPB nitric oxide administration can attenuate pulmonary hypertensive crises, facilitate separation from CPB, shorten ventilation and intensive care stay, and, in selected high-risk cohorts, may reduce cardiac surgery-associated acute kidney injury, although survival benefits remain unproven. Across these scenarios, iNO should be used judiciously and in a pathophysiology-driven manner as a time-limited, targeted adjunct to stabilize patients with documented or anticipated RV strain rather than a disease-modifying therapy. Future work should refine patient selection, timing, dosing, and weaning strategies, and define the long-term safety and cost-effectiveness of iNO within contemporary multimodal RV support pathways. Full article

Background/Objectives: The utility and value of graduated compression stockings (gCS) as an adjunct to pharmacological thromboprophylaxis, with and without low-molecular-weight heparins (LMWH) and other anticoagulants, in avoiding any thromboembolic (TE) event in the scenario of total joint replacement, fracture management, spine and pelvic surgery, and arthroscopic procedures, remains unclear. Because of the urgent need to decide whether gCS should stay in the portfolio of a national group of nine tertiary trauma centres, our research department was requested to answer the question of whether gCS provide any extra benefit in addition to modern TE prophylaxis in orthopaedic and trauma surgery through a prospectively registered rapid review (PROSPERO CRD42024621104). Methods: We searched PubMed, Ovid MEDLINE, Embase, CINAHL, and CENTRAL from 1 January 1980 to 1 March 2025, for randomised controlled trials (RCTs) and cohort studies comparing TE prophylaxis regimens, both with and without gCS, and modern pharmacological anticoagulants. The methodological quality of individual studies was rated by the Cochrane Collaborations’ Risk of Bias Version 2.0 (RoB-2) and the Risk of Bias in Non-Randomised Studies of Interventions (ROBINS-I) tools, supplemented by the Grading of Recommendations Assessment, Development and Evaluation (GRADE). The reported cumulative incidence of any TE event (i.e., deep vein thrombosis, pulmonary embolism), as defined by individual trialists, was chosen as the primary endpoint, and expressed as the relative risk (RR) between intervention and control groups. Results: Fifteen investigations (13 RCTs and 2 observational studies) enrolling 7721 patients (mean age, 59 [SD 13] years; 3538 males [46%]) with various musculoskeletal conditions and injuries were included. Methodological quality was deemed sufficient to derive meaningful conclusions. The random-effects pooled RR across all studies was 1.15 (95% confidence interval [CI]: 0.80–1.64) in favour of the no-gCS control, but with substantial heterogeneity (I²: 73%). Only three studies investigated the effectiveness of gCS versus no prophylaxis (N = 246, RR: 0.72, 95% CI: 0.43–1.22). Seven studies (N = 5117) compared various combinations of pharmacological prophylaxis, with or without gCS, for a summary RR of 1.44 (95% CI: 0.76–2.72). Conclusions: The results of this rapid review neither show a clear benefit nor support the general use of gCS to prevent TE in orthopaedic and trauma surgery, especially if pharmacological prophylactic measures are established and suitable. Full article

Objectives: Pulmonary embolism (PE) is an uncommon but potentially fatal complication of acute ischaemic stroke (AIS). Its global burden and prevention remain incompletely defined. We performed a systematic review and meta-analysis (PEARL-AIS) to estimate prevalence, risk factors, outcomes, and prophylactic efficacy, with GRADE evidence appraisal. Methods: Following PRISMA 2020 and MOOSE guidelines, five databases (PubMed, Embase, Cochrane, Scopus, Web of Science) were searched (1995–2024). The protocol was prospectively registered (OSF s25ny). Random-effects models (DerSimonian–Laird; REML sensitivity) were used to pool prevalence and odds ratios; heterogeneity was evaluated with I², Cochran’s Q, and τ². Influence (leave-one-out) and subgroup analyses for prevalence and mortality of PE in AIS were explored. Bias was assessed using the Modified Jadad Scale; overall certainty was graded with the GRADE framework. Results: Twenty-four studies met the inclusion criteria (n = 25,666,067), of which seventeen studies (n = 23,637,708) contributed to pooled prevalence analyses. The pooled prevalence of PE after AIS was 0.40% (95% CI 0.33–0.49), approximately six-fold higher than in the general population, with considerable heterogeneity (I² > 90%, Cochrane classification). The pooled mortality among AIS patients with PE was 12.9% (95% CI 1.6–31.7). Mortality risk was significantly higher in AIS patients with PE (OR 4.96, 95% CI 2.98–8.24). Atrial fibrillation (29%), cancer (19%), and smoking (23%) were common; hypertension (54%) and diabetes (23%) were prevalent but not predictive, with diabetes showing a paradoxical protective association (OR 0.88, 95% CI 0.84–0.92). Pharmacological prophylaxis was associated with a reduced risk of PE (OR 0.64, 95% CI 0.46–0.90; I² = 0%), supported by moderate-certainty evidence. Conclusions: PE is an uncommon but often fatal complication of AIS. Traditional venous thromboembolism predictors underperform in this context, suggesting a stroke-specific thromboinflammatory mechanism linking the brain and lung axis. Despite considerable heterogeneity and low-to-moderate certainty of evidence, pharmacological prophylaxis demonstrates a consistent protective effect. Systematic PE surveillance and tailored prophylactic strategies should be integral to contemporary stroke care, while future studies should refine risk stratification and elucidate the mechanistic underpinnings of this brain–lung thromboinflammatory continuum. Full article

Acute pulmonary embolism (APE) remains a significant cause of mortality and morbidity despite increasing prophylaxis for deep venous thrombosis (DVT). The IVC filter is a temporary or permanent intravascular device that traps migrating thrombi from their origin in the pelvis or a lower limb into the pulmonary vasculature, thereby preventing significant APE. The current and longstanding indications for placing an IVC filter are in patients with documented lower extremity DVT and acute APE who also have absolute contraindications to anticoagulation or have experienced an acute, hemodynamically unstable APE requiring ventilatory and vasoactive support, with limited cardiovascular reserve. Updated guidelines have led to a significant rise in IVC filter placements for specific therapeutic indications of venous thromboembolism compared to prophylactic use. Meta-analyses show that IVC filter placement is associated with a lower risk of subsequent APE but an increased risk of DVT. However, there appears to be no significant reduction in APE-related mortality and no change in all-cause mortality. Early complications after IVC filter placement typically relate to procedural issues and include bleeding or infection at the venous access site, development of arteriovenous fistulas, accidental arterial puncture, and post-procedural access site hematoma or thrombosis. Additional early complications include IVC filter malposition, incomplete expansion, IVC penetration, or guidewire entrapment. Delayed complications may involve DVT below the filter, IVC occlusion due to the filter, IVC filter migration, fracture of one of the IVC filter components, IVC rupture, or IVC thrombosis. Retrieval of IVC filters by simple, advanced, or open techniques should be considered after weighing the risk-to-benefit for the individual patient. Deployment of the IVC filter remains an important component of interventional APE management within the narrow indications currently proposed. Current guidance recommends that an untethered temporary IVC filter should be placed and retrieved once the contraindication to anticoagulation is resolved. Full article

Background/Objectives: To evaluate the diagnostic performance of non-enhanced MRA in detecting intratumoral aneurysms in renal AML, using digital subtraction angiography (DSA) as the reference standard. Methods: Fourteen female patients (mean age, 39 years; range, 21–57 years) who received prophylactic transcatheter arterial embolization (TAE) for non-hemorrhagic renal AML(s) between July 2010 and September 2018 were included in this study. All received a non-enhanced MRA scan prior to TAE. Non-enhanced MRA images were obtained using the flow-in technique with three-dimensional balanced steady-state free precession (SSFP). The MRA and DSA images were jointly evaluated by three radiologists. In this study, significant aneurysms were defined as aneurysms with a diameter of 3 mm or more within the renal AML. The MRA images assessed the number and location of significant aneurysms. The DSA images were used as the reference standard. Results: DSA identified 30 significant aneurysms in eight kidneys; MRA identified 26, giving a sensitivity of 87%. There were no false positives, resulting in a specificity of 100%. Conclusions: Flow-balanced SSFP MRA is effective in detecting significant aneurysms in renal AML and could be a viable alternative for patient follow-up. Full article

Background: The optimal anticoagulation strategy for obese patients with superficial vein thrombosis (SVT) remains unclear. This study evaluates the impact of obesity on anticoagulation patterns and clinical outcomes in patients with lower limb SVT. Methods: We conducted a prospective observational study including consecutive patients with SVT in a tertiary hospital from 2014 to 2024. Patients with SVT ≥ 5 cm in length and ≥3 cm from the saphenofemoral junction were included. Obese (BMI ≥ 30) and non-obese (BMI < 30) patients were compared. Patients were followed for one year. Outcomes were assessed at 90 and 365 days. The primary outcomes were venous thromboembolism (VTE) recurrence (SVT, deep vein thrombosis [DVT], or pulmonary embolism [PE]). The secondary outcomes were major bleeding and all-cause mortality. Results: Of 136 patients, 58 (42.6%) were obese. Both groups had similar baseline characteristics, except for younger age and higher smoking prevalence in obese patients. Most patients received anticoagulation (91.9%), primarily a prophylactic dose of low molecular weight heparin or a prophylactic dose of fondaparinux. No significant differences were found in VTE recurrence at 90 or 365 days (p = 0.505), and no major bleeding events occurred. Female sex was associated with a higher risk of VTE recurrence (OR 4.33, 95% CI 1.17–15.98, p = 0.028), but obesity did not influence outcomes. Conclusions: Obesity was not associated with increased VTE recurrence in patients with lower limb SVT. No major bleeding events were observed. These findings suggest that standard anticoagulation regimens may be appropriate for obese patients with SVT, but further studies are needed to confirm these results. Full article

Pulmonary embolism (PE) is an under-recognised yet serious complication in patients with acute ischaemic stroke (AIS), contributing significantly to morbidity and mortality. The interplay of traditional risk factors—such as immobility, endothelial dysfunction, and hypercoagulability—with AIS-specific conditions, including atrial fibrillation, malignancy, and reperfusion therapies, complicates both diagnosis and management. Despite available prophylactic strategies, including low-molecular-weight heparin and intermittent pneumatic compression, their use remains limited by bleeding concerns and a lack of tailored guidelines. This review synthesises the current evidence on the incidence, risk factors, pathophysiology, diagnostic approaches, and preventive strategies for PE in AIS, identifying critical gaps in risk stratification and clinical decision-making. We propose a novel mechanistic framework—the Brain–Lung Thromboinflammatory Axis Hypothesis—which posits that stroke-induced systemic inflammation, neutrophil extracellular trap (NET) formation, and pulmonary endothelial activation may drive in situ pulmonary thrombosis independent of deep vein thrombosis. This conceptual model highlights new diagnostic and therapeutic targets and underscores the need for stroke-specific VTE risk calculators, biomarker-guided prophylaxis, and prospective trials to optimise prevention and outcomes in this vulnerable population. Full article

Background: Although thromboembolic complications are recognized in the treatment of acute lymphoblastic leukemia (ALL), ischemic strokes are rare but severe events. These life-threatening complications not only pose an immediate risk but can also result in long-term neurological deficits, significantly impacting a patient’s quality of life. Identifying high-risk patients and implementing effective prophylaxis strategies are crucial for improving patient outcomes. In addition to strokes, these patients are also at risk of other embolic and thrombotic events, which can occur in up to 35% of patients. Despite this, there are still no clear guidelines for prophylactic management in pediatric patients treated for oncologic diseases. Results: Using the example of a 14-year-old male treated for ALL who suffered an ischemic stroke, we conducted a review of the literature on embolic and thrombotic events, neurological complications, methods of prevention, and ways to monitor and detect patients with an increased risk of such difficulties. We outlined our approach to the monitoring of prothrombotic factors, the interpretation of their levels, and the subsequent adjustment to prophylactic management based on these findings. As a result of this review, we reached two basic conclusions. First, thromboembolic episodes are not uncommon complications in pediatric patients and can cause long-lasting consequences, even after the cancer is cured. Secondly, despite such an urgent problem, clinicians are still struggling with the question of monitoring prothrombotic factors, the choice of drug, and the duration of prophylaxis. Their decisions depend on the experience of the treating center. Conclusions: The pediatric population being treated for malignant disease urgently requires the establishment of guidelines that standardize the management of thromboembolic events. Full article

Background: Internal jugular vein thrombosis (IJVT) is a rare but serious complication in hospitalized patients, often associated with central venous access devices (CVADs). The primary objective of the study was to analyze the clinical characteristics of patients with newly diagnosed IJVT, in particular to evaluate mortality, development of pulmonary embolism and incidence of bleeding at 30 days from diagnosis. Secondly, a sub-analysis was performed between patients with device-related and non-device-related thrombosis. Methods: Prospective study on adult inpatients diagnosed with IJVT from January to December 2024. Data on demographics, comorbidities, device use, laboratory values at diagnosis (D-dimer, platelet count, C-reactive protein (CRP), liver/renal function), treatment, and outcomes (mortality, pulmonary embolism, bleeding) were collected. Results: Thirty-one patients with IJVT were included. Mean age was 71.0 ± 13.2 years; 54.8% female; 35.5% had CVADs (central venous catheter (CVC) 36.4%, midlines 36.4%, peripherally inserted central catheter (PICC) 27.2%). Device-associated IJVT patients exhibited lower D-dimer (2.1 ± 0.5 vs. 3.6 ± 0.8 µg/mL; p = 0.018), higher platelet counts (249.0 ± 86.7 vs. 184.3 ± 53.6 × 10⁹/L; p = 0.044), and elevated CRP (12.5 ± 9.2 vs. 5.1 ± 5.6 mg/L; p = 0.033). Overall mortality was 16.1%; pulmonary embolism occurred in 16.1% and bleeding in 6.5%. CVAD use was not independently associated with adverse outcomes. Conclusions: IJVT presents with distinct biomarker profiles when associated with CVADs, characterized by lower systemic fibrinolysis and heightened inflammation. Recognition of these differences may refine diagnostic thresholds and guide prophylactic strategies. Larger prospective studies are warranted. Full article

Objective: In patients with leg injuries, typical symptoms of thrombosis such as painful swelling may be misinterpreted as a consequence of the trauma. This has the potential to result in an unexpected embolism, especially during the perioperative period. This study investigates the incidence of unapparent preoperative deep-vein thrombosis (DVT) in patients with traumatic intraarticular tibial plateau fracture (TPF). A comprehensive analysis was conducted to identify possible risk factors, with particular attention paid to fracture severity and soft tissue injury. Methods: This retrospective single-centre study evaluated patient data from November 2021 to November 2024. It included 72 patients with traumatic intraarticular TPF who underwent surgery and received a preoperative compression ultrasonography screening. Results: The incidence of preoperative DVT was 23.6% (n = 17). Among these, 5.6% (n = 4) exhibited proximal thrombosis, while 18.1% (n = 13) demonstrated distal thrombosis. The fibular veins were predominantly affected (12/17). Patients with DVT suffered high-energy traumata, dislocations, compartment syndromes, and complex fractures (AO/OTA type C3: 82.4% vs. 52.7%) more often than patients without DVT and were more often immobilised with an external fixator. In 47.1% of DVT cases (n = 8), surgery could no longer be postponed, and an inferior vena cava filter was temporarily employed. The removal of the filter was successful in all cases, with no major complications encountered. Conclusions: This study reveals a high incidence (23.6%) of unapparent preoperative DVT in patients with traumatic intraarticular TPF despite prophylactic anticoagulation, particularly in those with severe fractures and soft tissue injuries. Systematic DVT screening and early anticoagulation are crucial to avoid potentially life-threatening complications. Full article

Background/Objectives: Deep inferior epigastric perforator (DIEP) flap reconstruction is considered the gold standard for autologous breast reconstruction due to its favorable aesthetic results and low donor site morbidity. Nevertheless, it remains associated with potentially life-threatening complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE). This report aims to describe a complex clinical case in which severe thromboembolic and ischemic complications occurred despite adherence to standard prophylactic protocols. Methods: We present the case of a 65-year-old female with multiple thromboembolic risk factors—including obesity, a history of heavy smoking, hormone therapy, and prior COVID-19 infection—who underwent immediate bilateral breast reconstruction with DIEP flaps following mastectomy. Results: Within the first 24 h postoperatively, the patient developed a massive pulmonary embolism requiring intensive care management. Despite appropriate anticoagulation and supportive measures, she subsequently experienced full-thickness necrosis of the central portion of the abdominal flap. Thrombophilia screening and diagnostic imaging did not reveal peripheral venous thrombosis, raising the hypothesis of a hypercoagulable state potentially related to prior SARS-CoV-2 infection. Conclusions: This case underscores the importance of individualized risk stratification and suggests that current prophylaxis protocols may be insufficient for patients with overlapping thrombotic risk factors. The findings advocate for further investigation into the long-term vascular effects of COVID-19 and support reconsidering extended or intensified prophylaxis in high-risk populations undergoing complex microsurgical procedures. Full article

Background: Neuroendocrine neoplasms (NENs) are a heterogeneous group of tumors with unique biological characteristics and complications, including thromboembolism. This systematic review evaluates the incidence, types, and clinical outcomes of venous thromboembolic events (VTEs) in NEN patients. Methods: A systematic search of PubMed, Scopus, and Embase was conducted to identify studies on TEs in NENs. Eligible studies included case reports, case series, and retrospective cohort studies reporting VTEs, including deep vein thrombosis (DVT), pulmonary embolism (PE), and visceral vein thrombosis (VVT). Data were extracted on tumor site, functionality, differentiation grade, and VTE type. Results: In total, 33 studies were included, comprising 26 case reports, 2 case series, and 5 retrospective cohort studies. VTE prevalence ranged from 7.5% to 33% across studies. The most common VTEs were DVT, PE, and portal vein thrombosis (PVT). A meta-analysis revealed a pooled VTE prevalence of 11.1% (95% CI: 9.07–13.53%). Pancreatic NENs exhibited the highest thrombotic burden, particularly in poorly differentiated and advanced-stage tumors. Functioning tumors, including glucagonomas and ACTH-secreting NENs, were strongly associated with VTEs, potentially related to their systemic effects on coagulation and inflammation. Conclusions: Venous thromboembolism is a significant complication in NEN patients, especially in advanced or poorly differentiated tumors. Early detection and targeted management are critical for improving outcomes. Further investigations are required to clarify the mechanisms underlying thromboembolism in NENs and to develop optimized prophylactic and therapeutic strategies tailored to this patient population. Full article