Search Results (21)

Thrombotic complications represent uncommon but potentially life-threatening adverse events associated with assisted reproductive technologies (ARTs), particularly in the setting of controlled ovarian stimulation and ovarian hyperstimulation syndrome (OHSS). The relationship between thrombophilia, infertility, ovarian hyperstimulation syndrome (OHSS), and venous thromboembolism (VTE) remains complex and only partially understood. While antiphospholipid syndrome is a well-established acquired thrombophilic disorder associated with recurrent pregnancy loss, the association between common inherited thrombophilias and recurrent pregnancy loss is less consistent, and their contribution to primary infertility and implantation failure remains uncertain. Conversely, severe OHSS is consistently recognized as the principal treatment-related determinant of thrombotic events during IVF because of profound endothelial activation, hemoconcentration, and hypercoagulability. This narrative review summarizes the current evidence regarding the epidemiology, pathophysiology, and clinical presentation of thrombotic complications associated with assisted reproductive technologies, including deep vein thrombosis, pulmonary embolism, cerebral venous thrombosis, upper-extremity thrombosis, splanchnic vein thrombosis, and arterial thrombotic events. Current recommendations for thromboprophylaxis, diagnostic strategies, and therapeutic management are critically discussed, with particular attention to individualized risk assessment and the role of low-molecular-weight heparin in high-risk patients. Although routine thromboprophylaxis is not recommended for all women undergoing in vitro fertilization (IVF), careful evaluation of patient-specific thrombotic risk factors remains essential. Future prospective studies are needed to improve risk prediction, optimize preventive strategies, and establish evidence-based recommendations for women undergoing assisted reproduction. Full article

Background/Objectives: Paget–Schrotter syndrome (PSS), or primary axillary-subclavian vein thrombosis, is an uncommon but clinically important form of upper extremity deep vein thrombosis. It often affects young, physically active patients and may initially be interpreted as a musculoskeletal disorder. This scoping review, combined with a contemporary primary care case, aimed to map the reported clinical presentation, diagnostic delay, and initial misdiagnosis of classic PSS. Methods: The review was conducted using the Arksey and O’Malley framework and reported in accordance with the PRISMA extension for scoping reviews (PRISMA-ScR). PubMed was searched for English-language publications from 1 January 2000 to 1 March 2026. Eligible reports described effort-induced thrombosis involving the axillary and/or subclavian venous segment. Secondary upper extremity deep vein thrombosis, non-effort thrombosis, pseudo-PSS, isolated distal venous thrombosis, and reports without extractable patient-level presentation data were excluded. Data were charted descriptively. Results: Among 1954 screened records, 143 studies met inclusion criteria and contributed 165 published patients. Together with the present case, the synthesis included 166 patients. Median age was 28 years, and 73.5% were male. Arm swelling (95.2%), pain (80.1%), cyanosis or discoloration (69.9%), and venous distension (70.5%) were the most frequent presenting features. Diagnostic delay was reported in 27.3% of patients with reported data, whereas initial misdiagnosis was reported in 21.7% of included patients. Musculoskeletal injury or muscle strain was the most common initial misdiagnosis, accounting for 66.7% of misdiagnosed cases. Pulmonary embolism was reported in 24.7% of patients, although this reported frequency is likely influenced by case-report publication bias, selective imaging, and preferential reporting of more severe presentations, and should not be interpreted as a population-level risk estimate. Conclusions: PSS should be considered in young or otherwise low-risk patients with unilateral arm swelling after strenuous or repetitive upper extremity activity. Greater awareness of this clinical presentation in primary care and general emergency settings may reduce diagnostic delay and post-thrombotic morbidity. Full article

Background: Venous thromboembolism (VTE) remains a clinically relevant complication following major orthopaedic procedures, particularly total hip arthroplasty (THA), total knee arthroplasty (TKA), and fracture surgery. Although low-molecular-weight heparin (LMWH) and direct oral anticoagulants (DOACs) are widely regarded as standard pharmacological options, aspirin (acetylsalicylic acid, ASA) has gained renewed attention because of its low cost, oral administration, and favourable bleeding profile. However, the available evidence is heterogeneous, and its interpretation is complicated by differences in patient selection, timing and duration of prophylaxis, diagnostic methodology, aspirin dosing regimens, and the increasing adoption of modern fast-track arthroplasty pathways. Methods: A structured evidence-based review was conducted in accordance with PRISMA 2020 principles. PubMed, Embase, Web of Science, and the Cochrane Library were searched through September 2025 for randomised controlled trials (RCTs), major international clinical practice guidelines, and selected high-level studies relevant to the interpretation of aspirin-based orthopaedic thromboprophylaxis. Nine RCTs, four major guideline documents, and sixteen additional Level I–II studies were included. Outcomes of interest were symptomatic deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, and mortality. Risk of bias was assessed using the Cochrane ROB 2 framework. Owing to marked methodological heterogeneity, no formal pooled meta-analysis was undertaken. Results: The available RCT evidence suggests that aspirin may perform adequately within structured sequential or risk-stratified prophylaxis strategies, but not in all clinical settings. In arthroplasty, EPCAT II demonstrated non-inferiority of aspirin when introduced after an initial five-day course of rivaroxaban, whereas CRISTAL showed higher early symptomatic VTE rates when aspirin was used as sole primary prophylaxis from postoperative day 0. Importantly, thromboembolic events in CRISTAL occurred earlier in the aspirin cohort, supporting the concept that anticoagulant therapy remains important during the immediate postoperative hypercoagulable phase. In trauma surgery, PREVENT CLOT established non-inferiority of aspirin compared with LMWH for 90-day mortality; however, the predominantly young study population and the inclusion of upper-extremity fractures limit extrapolation to elderly hip fracture patients. Several smaller RCTs reported no major differences between aspirin and anticoagulants, but these studies were frequently underpowered and relied on less sensitive diagnostic strategies. Historical and contemporary guidelines remain heterogeneous, and evidence from modern fast-track arthroplasty pathways suggests that current trial-based conclusions may not be directly generalisable to short-duration prophylaxis settings. Conclusions: Aspirin may have a role in orthopaedic thromboprophylaxis when used within structured, risk-adapted or sequential protocols, particularly in standard-risk arthroplasty patients and selected trauma populations. However, current evidence does not support its universal use as sole primary prophylaxis in major orthopaedic surgery, especially during the early postoperative hypercoagulable phase or in high-risk patients. Furthermore, the available literature does not permit definitive recommendations regarding the optimal aspirin dose or duration of prophylaxis. The generalisability of the existing literature is further limited by methodological heterogeneity and by the absence of RCTs directly evaluating ultra-short anticoagulant regimens versus prolonged aspirin prophylaxis in modern fast-track arthroplasty. Further high-quality, standardised trials are required. Full article

Background: Peripherally inserted central catheters (PICCs) are widely used for medium- and long-term intravenous therapies but remain associated with mechanical and thrombotic complications, particularly during venipuncture and guidewire insertion. The growing use of Non-Operating Room Anesthesia (NORA) environments, where anesthesiologists frequently perform ultrasound-guided vascular access under conditions of limited resources and support, underscores the need for simple, reproducible, and inherently safe techniques. The objective of this technical note is to describe a modified ultrasound-guided venipuncture technique for non-tunneled PICC insertion, specifically developed for NORA settings, aimed at reducing procedure-related complications and preserving patient safety in routine clinical practice. Methods: The proposed technique consists of controlled intraluminal advancement of the needle tip (approximately 0.3–0.5 cm) under continuous ultrasound visualization, combined with progressive reduction in the insertion angle to achieve stable central intraluminal alignment before guidewire insertion. The technique has been applied in routine clinical practice across multiple Italian centers over the last two years, within a large multicenter real-world experience exceeding 5000 non-tunneled PICC procedures. Results: Based on real-world clinical observations, the systematic application of the technique was associated with a low incidence of early mechanical complications, including failed guidewire advancement, multiple venipuncture attempts, local pain, and hematoma formation. During standardized post-procedural ultrasound follow-up of the catheterized upper-extremity veins, no cases of catheter-related deep vein thrombosis were detected. Conclusions: This modified ultrasound-guided venipuncture technique represents a feasible and reproducible procedural refinement for non-tunneled PICC insertion in NORA environments. By enhancing intraluminal needle stability during guidewire advancement, it may contribute to improving procedural reliability and supporting patient safety in routine clinical practice. Further prospective and comparative studies are warranted to confirm these findings and define the generalizability of this approach. Full article

Background/Objectives: Venous thromboembolism (VTE) is a major cardiovascular complication in cancer patients and the leading cause of morbidity and mortality. The aim of the study was to evaluate the incidence, timing, clinical predictors, and management of VTE in patients with breast cancer (BC), undergoing oncological therapy, and to propose a risk-adapted strategy for thrombosis monitoring and prevention. Methods: In this retrospective single-center study, 116 women with histologically confirmed BC (stages I–IV) treated between 2021 and 2024 were included. Patients were divided according to the occurrence of objectively confirmed VTE. Clinical characteristics, comorbidities, laboratory parameters, cancer-related factors, and treatment modalities were analyzed. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of VTE. Results: VTE occurred in 25 patients (21.6%), predominantly within the first 12 months after cancer diagnosis. Patients who developed VTE were significantly older and more frequently had hypertension, dyslipidemia, hyperglycemia, anemia, and leukocytosis. Multivariate analysis identified age ≥ 55 years, poor performance status (ECOG ≥ 3), and elevated glucose level as independent predictors of VTE. Deep vein thrombosis of the lower and upper extremities was the most common manifestation (52%), while pulmonary embolism was present in 24% of cases, either alone or in combination (20%). Direct oral anticoagulants were the most frequently used long-term anticoagulant therapy. Conclusions: VTE is a clinically relevant and relatively frequent complication in patients with BC, particularly during the early period of anticancer treatment. Patient-related and metabolic factors play a key role in thrombosis risk, underscoring the need for individualized, risk-adapted approaches to VTE prevention and monitoring in these populations. Full article

Background: Preserving arm veins is important for arteriovenous fistula (AVF) creation in patients with advanced chronic kidney disease (CKD), as mature AVF is the preferred hemodialysis access. Midline catheters introduced into AVF candidate veins may cause thrombosis, hindering AVF formation. This study aims to determine ultrasonographic rates of midline-associated upper extremity deep venous thrombosis (UE-DVT) or superficial venous thrombosis (SVT) in patients with advanced CKD. Methods: We conducted a prospective study involving subjects with advanced CKD, who had a point-of-care ultrasound-guided midline placed in an arm vein. Within 35 days of midline insertion, participants underwent routine bilateral UE venous duplex ultrasound. The primary outcome was a composite occurrence of UE-DVT/SVT ipsilateral to the midline. Comparative analyses were performed based on patient demographics and device-specific variables. Results: 49 subjects with advanced CKD received midlines. The median midline catheter dwell time was <6 days for 15/49 patients (30.6%). The primary outcome occurred in 15/49 patients (30.6%), mostly asymptomatic thrombosis. No significant associations were found between outcomes and patient or device characteristics. Conclusions: Our study identified frequent use of midlines with short dwell times in subjects with advanced CKD which calls into question proper device selection. In this cohort, midline-associated arm clots were frequent. Full article

Background/Objectives: Unusual-site venous thrombosis (USVT) lacks robust evidence guiding anticoagulant selection between vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). This study aimed to evaluate recanalization, recurrence, and major bleeding outcomes in real-world USVT patients and to replicate these findings through a validated digital twin model with Monte Carlo simulation. Methods: We conducted a retrospective study of 90 USVT patients (72% VKAs, 28% DOACs). A conditional generative adversarial network was used to generate digital twins matched on age, sex, thrombosis site, and malignancy. Logistic regression was applied to estimate treatment-specific outcome probabilities for recanalization, recurrence, and major bleeding. A nested stochastic simulation framework simulated 500 iterations across clinical scenarios, including increased DOAC use, cancer prevalence, cerebral vein thrombosis proportion, and optimized VKA control. Results: The mean age was 67.5 years, and 54.4% were female. 61.1% of splanchnic vein thrombosis, 36.7% of upper extremity deep vein thrombosis, and 2.2% of cerebral vein thrombosis were included. In the real cohort, complete recanalization occurred in 40.0% of patients with DOACs and 36.0% with VKAs. Recurrence was 8.0% with DOACs and 7.7% with VKAs, and major bleeding occurred in 8.0% and 10.8% of cases, respectively. All-cause mortality was 20% in DOAC-treated patients and 60% in those receiving VKAs. Digital Twin-based predictions replicated these results (recanalization 40.3% versus 38.0%; recurrence 10.9% versus 8.6%; bleeding 7.6% versus 9.1%). Simulated scenarios preserved the directionality effect, with the most significant differences observed in high-cerebral vein thrombosis and cancer-enriched patients. Conclusions: DOACs showed comparable efficacy and slightly lower bleeding risk than VKAs in USVT. Digital twin and Monte Carlo modeling provided robust, reproducible simulations of treatment effects under varying clinical conditions. Separating empirical and simulation-based findings, the digital twin supported the internal consistency of real-world observations and demonstrated the potential of in silico modeling as a complementary tool in rare thrombotic diseases. Full article

Background/Objectives: Upper extremity deep vein thrombosis (UEDVT) is a harmful complication of elective upper limb surgeries. Different strategies are employed to prevent this condition. The aim of the review is to quantify the effectiveness of various preventive interventions and investigate correlated factors that affect the incidence of UEDVT (upper extremity deep vein thrombosis). Methods: We performed a systematic search using the PubMed, EBSCO, Ovid, EMBASE, Cochrane, and Google Scholar databases. Randomized controlled trials (RCTs), prospective or retrospective cohort studies, or case–control studies were examined. We included adult patients over 18 years old undergoing elective upper limb surgery and receiving Prophylactic measures for Upper Extremity Deep Venous Thrombosis. Results: After a literature search and quality assessment, 6 studies were included. All the studies were of good quality but significantly heterogeneous in terms of sample size, population size, treatment modalities, and baseline characteristics. In these studies, the reported incidence of symptomatic venous thromboembolism (VTE) varied widely, ranging from 0.41% to 13%. However, thromboprophylaxis did not have a significant impact on the rates of deep vein thrombosis (DVT). Certain factors such as older age and trauma as the cause of surgery were identified as notable risk factors for symptomatic VTE. Conclusions: This systematic review highlights the complexity of preventing upper extremity deep vein thrombosis (UEDVT) following elective upper limb surgeries. The reported incidence of symptomatic VTE varies considerably across studies, and thromboprophylaxis was not associated with a significant reduction in its rates. The evidence is characterized by substantial heterogeneity in patient populations and surgical contexts. More research is needed to better understand the role of thromboprophylaxis in preventing DVT. Full article

Background: Mycotic aneurysms of the subclavian artery are infrequent and pose significant diagnostic challenges, particularly in the context of recurrent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. The concomitant presence of upper extremity deep vein thrombosis (UEDVT) further complicates the management of bleeding risk and the necessity for anticoagulation therapy. Methods: This report discusses a 75-year-old male patient with a medical history of lung and skin cancer undergoing immunotherapy who presented with a swollen and painful right arm. Ultrasound examination identified deep vein thrombosis in the right axillary and basilic veins, and blood cultures confirmed MRSA infection. Subsequent imaging revealed bilateral subclavian artery aneurysms with contained ruptures involving previously placed stent grafts. Emergent endovascular interventions were performed to prevent catastrophic hemorrhage. Results: Despite the initial interventions, concerns regarding infected stent grafts persisted due to ongoing MRSA bacteremia and the presence of an endoleak. The complexity of balancing anticoagulation for DVT with the risk of aneurysm rupture necessitated the patient’s transfer to a tertiary care center for potential open surgical debridement. Conclusions: This case underscores the diagnostic and therapeutic challenges associated with the simultaneous occurrence of vascular infection, thrombosis, and aneurysmal pathology. Although emergency endovascular repair provided temporary hemostatic control, definitive management may require graft removal if stent infection is confirmed. Optimal care in such complex clinical scenarios demands a multidisciplinary approach and may necessitate advanced surgical interventions. Full article

Direct oral anticoagulants (DOACs) have emerged as the preferred oral anticoagulant therapy for patients with deep vein thrombosis of the lower extremities and pulmonary embolism. DOACs offer several advantages over vitamin K antagonists, including fixed dosage, fewer drug interactions, faster onset of action, and a lower risk of major bleeding, especially intracranial. Although evidence on the use of DOACs in unusual-site venous thrombosis (USVT) is limited, their use in such cases is becoming increasingly common. This narrative review examines the evidence derived from randomized controlled trials, and large observational studies focused on the use of the DOACs in USVT, including cerebral, splanchnic, upper extremity, ovarian, renal, and retinal vein thrombosis. In addition, it also provides practical advice for their use in these clinical settings according to the updated scientific literature. Full article

Deep venous thrombosis (DVT) is a pathological condition that develops when a thrombus forms within the deep venous system. Typically, it involves the lower limbs and, less frequently, the upper extremities or other unusual districts such as cerebral or splanchnic veins. While leg DVT itself is rarely fatal and occasionally can lead to limb-threatening implications, its most fearsome complication, namely pulmonary embolism, is potentially fatal and significantly contributes to increased healthcare costs and impaired quality of life in affected patients and caregivers. Thanks to its high accuracy, ease of use, and safety profile, duplex ultrasound (DUS), particularly compression ultrasound (CUS), has emerged as the first-line imaging modality for DVT diagnosis. The evaluation of suspected DVT needs a multifaceted approach, and in this context, CUS rapidly became a key diagnostic tool owing to its many unique advantages. Its central role in the diagnostic algorithm of suspected DVT is clearly established in the latest clinical practice guidelines from the European Society for Vascular Surgery and the American Society of Haematology. Indeed, DUS effectively visualizes blood flow and identifies abnormalities like clot formation with high sensitivity (typically exceeding 90% for proximal DVT) and specificity (often approaching 100% for proximal DVT). Additionally, CUS is non-invasive, readily available at the bedside, and avoids radiation exposure, resulting in an ideal method for various clinical settings. CUS has been shown to have a substantial role not only in the diagnosis of an acute DVT but also in the follow-up of its management. Moreover, this method can provide a prognostic assessment, mostly in terms of risk stratification for recurrent thrombosis and/or for potential complications, such as post-thrombotic syndrome. In summary, given its established benefits, CUS is a technique that many physicians should be familiar with, especially those working in emergency departments, intensive care units, or general wards. When needed, healthcare operators with more advanced US skills (such as radiologists, angiologists, or vascular surgeons) may be called upon to provide a second look in case of uncertainty and/or need for additional information. Full article

Catheter-related thrombosis (CRT) is a frequent and potentially serious complication associated with the widespread use of intravascular devices such as central venous catheters, including peripherally inserted central catheters and implantable port systems, pacemakers or implantable cardioverter-defibrillators. Although CRT management has been informed by guidelines extrapolated from lower extremity deep vein thrombosis (DVT), unique challenges remain due to the distinct anatomical, pathophysiological, and clinical characteristics of upper extremity DVT. Risk factors for CRT are multifactorial, encompassing patient-related characteristics such as cancer, prior venous thromboembolism, and infection, as well as catheter-specific factors like device type, lumens, and insertion site. The diagnosis of CRT relies primarily on ultrasonography; however, computed tomography angiography and magnetic resonance imaging play a complementary role, particularly in anatomically challenging cases or when complications such as pulmonary embolism or superior vena cava syndrome are suspected. Treatment strategies for CRT include anticoagulation, catheter removal when feasible, and, in select cases, local thrombolysis or catheter-directed interventions. Anticoagulation remains the cornerstone of therapy, with direct oral anticoagulants increasingly favored due to their safety profile and efficacy. This article provides a detailed review of CRT, focusing on clinical features, diagnostic methods, and treatment strategies while addressing specific challenges in managing pacemaker and hemodialysis catheter-related thrombosis. Full article

Background: Upper extremity deep vein thrombosis (UEDVT) is uncommon but not insignificant. The current literature is limited, and the management is largely extrapolated from the treatment of lower extremity DVTs (LEDVT). Methods: A retrospective review was conducted on patients diagnosed with UEDVT at Northern Health, Victoria, Australia, between December 2010 and December 2022. Medical records were reviewed to assess baseline characteristics and treatment outcomes. The results were compared to our previously collected data for LEDVTs. Results: 137 patients with UEDVT were identified (52.6% females; median age 62 years, IQR 46–74 years). A total of 105 patients (76.6%) had at least one provoking factor at the time of diagnosis, most commonly malignancy (45.7%) and/or indwelling venous devices (58.1%). Fourteen patients (10.1%) were subsequently diagnosed with Paget–Schroetter syndrome, with nine receiving endovascular or surgical intervention. A total of 109 patients (79.6%) received limited therapeutic anticoagulation (median 3 months, IQR 1.5–6.0 months) with enoxaparin, the most common anticoagulant used. Six patients had major bleeding (5.2/100-patient-years), and seven developed clot progression while on anticoagulation (6.0/100-patient-years). Ten patients had recurrent VTE following anticoagulation cessation (4.6/100-patient-years). There were no significant differences seen in the complication rate between catheter-related UEDVT and other UEDVTs. Compared to LEDVT, UEDVT was more likely provoked with comparable complication rates. Conclusions: UEDVTs were commonly associated with a provoking factor, with indwelling catheters and/or malignancies being the most common. Interestingly, catheter-related UEDVT had comparable clot progression/recurrence and major bleeding compared to other UEDVTs and LEDVTs, which may be confounded by relatively high rates of malignancy. Full article

Once considered relatively benign, superficial vein thrombosis (SVT) of the lower limbs is linked to deep vein thrombosis (DVT) or pulmonary embolism (PE) in up to one fourth of cases. Treatment goals include alleviating local symptoms and preventing SVT from recurring or extending into DVT or PE. Fondaparinux 2.5 mg once daily for 45 days is the treatment of choice for most patients with SVT. Potential alternatives include intermediate-dose low-molecular-weight heparin or the direct oral factor Xa inhibitor rivaroxaban, however, these require further evidence. Despite these treatment options, significant gaps remain, including the role of systemic or topical anti-inflammatory agents alone or combined with anticoagulants, and the optimal duration of anticoagulation for patients at varying risk levels. Additionally, the efficacy and safety of factor Xa inhibitors other than rivaroxaban, management of upper extremity SVT, and optimal treatment for SVT near the sapheno-femoral or sapheno-popliteal junctions are not well understood. This narrative review aims to summarize current evidence on anticoagulant treatment for SVT, highlight key unmet needs in current approaches, and discuss how ongoing studies may address these gaps. Full article

Upper extremity deep vein thrombosis (DVT) of the axillary/subclavian veins is rare (5–10% of DVT). After clinical suspicion and duplex ultrasound, anticoagulation, surgical decompression and sometimes thrombolysis are mandatory due to complications. We discuss the case of a young healthy orchestra conductor with primary DVT of the left upper extremity and concomitant left shoulder musculo-tendinous traumatic injury. Symptoms of both conditions and subtle signs of upper extremity DVT delayed the diagnosis until full-blown DVT occurred. After successful anticoagulation and surgical TOS (thoracic outlet syndrome) decompression, evolution was favorable, without recurrent thrombosis. Full article