Search Results (108)

Background/Objectives: Multiple myeloma (MM) patients receiving immunomodulatory drugs (IMiDs) are at increased risk of venous thromboembolism (VTE). Standard prophylaxis typically involves aspirin or low-molecular-weight heparin (LMWH), guided by risk assessment tools such as SAVED and IMPEDE-VTE. However, these models have practical limitations, and real-world evidence supporting novel oral anticoagulants (NOACs) as primary prophylaxis remains limited. Methods: In this retrospective, single-center study, we analyzed 101 MM patients treated with IMiD-based therapy between January 2020 and December 2024. All patients received NOAC prophylaxis (apixaban 2.5 mg twice daily or rivaroxaban 10–20 mg once daily), irrespective of baseline thrombotic risk. Clinical characteristics, comorbidities, and treatment details were collected. The primary outcome was objectively confirmed VTE, while secondary outcomes included bleeding events and treatment feasibility, assessed by treatment continuation without clinically significant bleeding. Results: Median age was 63 years (range 35–89); 36.6% were female. Lenalidomide and pomalidomide were used in 86.1% and 13.9%, respectively. Twenty-eight patients (27.7%) had relapsed/refractory disease, while 72.3% were newly diagnosed. Over a median NOAC exposure of 6 months, two patients (2.0%) developed VTE (both deep vein thrombosis). One major bleeding event (1.0%) occurred. Conclusions: Universal NOAC prophylaxis in MM patients receiving IMiD-based therapy was associated with a low incidence of thromboembolic events and an acceptable safety profile. These real-world findings suggest that NOACs may represent a practical and effective alternative to aspirin or LMWH, potentially overcoming the limitations of score-based prophylaxis strategies. Full article

Background: Venous thromboembolism (VTE) is associated with high morbidity and mortality. The activation of multiple pathways of venous thrombosis occurs after an injury. A prophylaxis protocol is necessary to prevent early and late venous thrombotic complications. Methods: This study aimed to evaluate the outcomes of venous thromboembolism using the Greenfield risk assessment profile score and its association with bleeding complications. This was a retrospective cohort study conducted on trauma cases who were aged 15 years or older. The study was conducted from January 2020 through December 2022. Patients who were admitted to hospital for less than 24 h or those who died during resuscitation or treatment in an emergency room were excluded from this study. Results: We enrolled 580 cases. Among them, 46.6% were categorized as high-risk for developing venous thromboembolism, and 30.4% of these high-risk patients received pharmaco-mechanical thromboprophylaxis. All VTE cases were high risk according to the Greenfield risk assessment profile, accounting for 3% of the entire group and 1.4% of all enrolled cases. All major bleeding complications occurred with a previously diagnosed large subdural hematoma. Conclusions: Assessing VTE risk was crucial for optimal management of prophylaxis. Proper use of pharmacological prophylaxis had to be balanced against the risk of bleeding complications. Full article

Objective: We investigated the relationship between venous thromboembolism (VTE) and pelvic and para-aortic lymphadenectomy (LND) within the first 90 days post gynaecological cancer surgery. Methods: A retrospective cohort analysis was conducted on 1021 patients who underwent gynaecological cancer surgery between 2006 and 2019. Univariate and multivariate analysis was performed to assess the effects of LND and lymph node (LN) metastasis on VTE occurrence within 90 days post-surgery. Results: A total of 41 patients developed VTE within 90 days post-surgery. Para-aortic LND was significantly associated with VTE (p < 0.001), with the highest rates (14.6%) observed in patients who had >10 para-aortic LN removed. In patients with pelvic LN metastasis, 10 (7.5%) developed VTE; patients with >5 pelvic nodes positive for metastasis had an HR = 4.83 (95% CI: 0.99–13.9) after adjustment for age, duration of hospital stay, and surgical approach. The highest VTE rates (27.3%) occurred in patients with >5 para-aortic LN positive for metastasis, HR = 3.79 (95% CI 1.44–14.23) after adjustment for age, duration of hospital stay, and surgical approach (p = 0.011). Conclusions: Para-aortic LND significantly increases VTE risk within the first 90 days post-surgery. The risk is further amplified in cases with metastatic LN and persists even after adjustment for other risk factors for VTE. While extended thromboprophylaxis is standard for all cancer patients, our findings suggest that para-aortic LND—especially with nodal metastases—may help identify those who would benefit most from a more tailored, risk-based prophylaxis approach. Full article

Background/Objectives: Venous thromboembolism (VTE) is a common and potentially fatal condition in hospitalized patients. Although appropriate risk assessment and prophylaxis reduce VTE events, preventive measures remain underutilized. This study aimed to evaluate the effectiveness of an electronic risk stratification tool within multifaceted interventions for implementing VTE prophylaxis protocols in adult clinical and surgical patients at Hospital Moinhos de Vento, Brazil. Methods: A prospective before-and-after hospital-based study was conducted from 2017 to 2019, including 772 patients admitted to clinical and surgical units for over 48 h. The electronic tool based on the Maynard risk assessment model classified patients’ VTE risk. Padua and Caprini scores served as reference standards for clinical and surgical patients, respectively. Prophylaxis was considered adequate if it complied with institutional protocols. Results: Globally, the Maynard model classified 0.9% as low risk, 76.4% intermediate, and 22.7% high risk, differing notably in orthopedic surgical patients. Overall prophylaxis adequacy was 69.3%, with no significant difference between phases. Orthopedic surgical patients showed a significant decrease in prophylaxis adequacy in phase 2 (p = 0.02). Conclusions: The Maynard model underestimated high-risk classification compared to Padua and Caprini scores, especially in orthopedic surgical patients. Implementation of the electronic tool alongside multifaceted interventions did not improve prophylaxis adequacy. Full article

Background/Objectives: Prevention and treatment of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major clinical issue in hospitalized patients. Some aspects of VTE management lack clarity due to differing physicians’ opinions and behaviors. Methods: A multidisciplinary steering committee identified two main areas of uncertainty: VTE prophylaxis and PE management in special settings. A multiple-choice questionnaire including 10 statements was circulated to 183 doctors trained in VTE management. The expected benefit-to-harm ratio was represented on a nine-point Likert scale, with consensus (≥75% agreement) on scores of 1–3 indicating inappropriate and 7–9 indicating appropriate care measures. Results: In online voting, a consensus was reached for 9/10 statements. Respondents considered the following to be appropriate: risk assessment of VTE (93.44%) and bleeding (91.6%) in hospitalized medical patients; low-molecular weight heparin (LMWH) prophylaxis for inpatients with pneumonia and malignancy (82.78%); therapeutic doses of LMWH/fondaparinux in patients with intermediate/high risk of PE with (80.9%) or without (77.97%) instability criteria; and echocardiography to manage patients with a post-PE syndrome (93.99%). Respondents considered the following to be inappropriate: use of 4000 IU LMWH in chronic renal failure (80.46%); use of 2000 IU LMWH in persons on dual antiplatelet therapy (77.01%); and use of low-dose apixaban (2.5 mg) in pregnancy (88.57%) or in subsegmental PE with hypoxemia (82.46%). No consensus was reached on the identification of PE cases eligible for outpatient treatment. Conclusions: Our findings show persistent gaps between guideline recommendations and clinical implementation despite improved awareness among physicians. Uncertainty persists regarding criteria for outpatient PE eligibility and/or for validation of bleeding-risk models. Full article

Background/Objectives: Venous thromboembolism (VTE) is the third most common cardiovascular condition, with higher rates among hospitalized patients. The limited efficacy of universal prophylaxis strategies has led to individual VTE risk assessments approaches. The main objective of this study was to assess outcomes in high-risk patients for VTE who receive prophylactic vs. intermediate, weight-adjusted doses of tinzaparin for thromboprophylaxis. Methods: This was a retrospective study assessing adult patients hospitalized with acute medical disease in a tertiary university hospital from January 2022–2024. Patients were included if found to be at high risk for VTE—as this reflected in Padua Prediction Score (PPS) ≥ 4—and received prophylactic versus intermediate dosage of tinzaparin. Data were collected from patients’ files and analyzed using appropriate statistical methods. Results: In total, 286 patients were included, of whom 160 received prophylactic and 126 intermediate tinzaparin dosage. The groups were comparable, except for arterial thrombosis history, central venous catheter presence, and median PPS. Patients receiving prophylactic doses exhibited significantly higher mortality rates (20.62 vs. 7.14, p = 0.002), increased length of stay (LOS) (6 vs. 4, p < 0.001), and prolonged treatment durations (5 vs. 3, p = 0.003) compared to patients receiving intermediate dosages. Univariate analysis revealed significant associations between mortality and tinzaparin dose (OR = 3.38, p = 0.002), age (OR = 1.03, p = 0.017), LOS (OR = 1.07, p = 0.001), PPS (OR = 1.62, p < 0.001), Charlson Comorbidity Index (CCI) (OR = 1.27, p < 0.001), and prior thrombotic events (OR = 2.27, p = 0.028). In multivariate analysis, tinzaparin dose (OR = 2.58, p = 0.035), age (OR = 1.04, p = 0.033), LOS (OR = 1.10, p < 0.001), and PPS (OR = 1.33, p = 0.038) remained independent predictors of mortality. Conclusions: These findings reveal that intermediate tinzaparin dosing is a more effective and safe approach in high-risk for VTE hospitalized patients, emphasizing the need for personalized VTE management. Full article

Stroke is the second-largest cause of death and disability worldwide, and many patients require intensive care for airway compromise, hemodynamic instability, cerebral edema, or systemic complications. This review summarizes key aspects of ICU management in both acute ischemic stroke (AIS) and hemorrhagic stroke (HS). Priorities are airway protection, oxygenation, individualized blood pressure targets, and strict control of temperature and glucose. Neurological monitoring and prompt management of intracranial pressure (ICP), together with timely surgical interventions (hemicraniectomy or hematoma evacuation), are central to acute care. Seizures are treated promptly, while routine prophylaxis is not recommended. Prevention of aspiration pneumonia, venous thromboembolism, infections, and other intensive care unit (ICU) complications is essential, along with early nutrition, mobilization, and rehabilitation. Prognosis and decisions about intensity of care require shared discussions with families and involvement of palliative services, when appropriate. Many practices remain based on observational data or extrapolation from other populations, underlining the need for stroke-specific clinical trials. Outcomes are consistently better when patients are managed in specialized stroke or neurocritical care units with a multidisciplinary treatment approach Full article

Background/Objectives: Pregnant women with Inflammatory Bowel Disease (IBD) require careful management to ensure optimal maternal and fetal outcomes. Whether IBD is a risk factor for pre-eclampsia is controversial. We aimed to investigate the incidence of venous thromboembolism (VTE), pre-eclampsia, and risk of disease flare from low-dose aspirin. Methods: This is a retrospective study of the Leeds combined IBD antenatal clinic providing joint specialist gastroenterology and obstetric consultations from 2015 to 2024. Primary outcomes were incidence of VTE, incidence of pre-eclampsia, and disease flare whilst taking aspirin. Results: In 574 pregnancies a single episode of VTE occurred. Adherence to VTE prophylaxis guidelines was good for post-partum periods but only 2 of 51 cases with third-trimester flare received the required VTE prophylaxis. The incidence of pre-eclampsia in this cohort was low at 2.7%. The majority of women deemed high-risk for pre-eclampsia received prophylaxis with aspirin in accordance with guidelines. The risk of symptomatic disease flare was not increased for aspirin users (21.6% versus 22.2% for non-users (p = 0.61)). Conclusions: The incidence of VTE and pre-eclampsia was low in this cohort of pregnant women with IBD. Pre-eclampsia prophylaxis in adherence to guidelines was good and was not associated with an increased flare risk. VTE prophylaxis for third-trimester flares was insufficient and requires better attention from IBD specialists, who are most likely to encounter patients with IBD flares. Full article

Background and Clinical Significance: Tandem pathology at the dominant-hemisphere middle cerebral artery (MCA)—combining a wide-neck bifurcation aneurysm that shares the neck with both M2 origins and a short dorsal M1 fusiform dilation embedded in the lenticulostriate belt—compresses the therapeutic margin and complicates device-first pathways. We aimed to describe an anatomy-led, microscope-only sequence designed to secure an immediate branch-definitive result at the fork and to remodel dorsal M1 without perforator compromise, and to place these decisions within a pragmatic perioperative framework. Case Presentation: A 37-year-old right-handed man with reproducible, load-sensitive cortical association and capsulostriate signs underwent high-fidelity digital subtraction angiography (DSA) with 3D rotational reconstructions. Through a left pterional approach, vein-respecting Sylvian dissection achieved gravity relaxation. Reconstruction proceeded in sequence: a fenestrated straight clip across the bifurcation neck with the superior M2 encircled to preserve both M2 ostia, followed by a short longitudinal clip parallel to M1 to reshape the fusiform segment while keeping each lenticulostriate mouth visible and free. Temporary occlusion windows were brief (bifurcation 2 min 30 s; M1 < 2 min). No neuronavigation, intraoperative fluorescence, micro-Doppler, or intraoperative angiography was used. No perioperative antiplatelets or systemic anticoagulation were administered and venous thromboembolism prophylaxis followed institutional practice. The bifurcation dome collapsed immediately with round, mobile M2 orifices, and dorsal M1 regained near-cylindrical geometry with patent perforator ostia under direct inspection. Emergence was neurologically intact, headaches abated, and preoperative micro-asymmetries resolved without new deficits. The early course was uncomplicated. Non-contrast CT at three months showed structurally preserved dominant-hemisphere parenchyma without infarction or hemorrhage. Lumen confirmation was scheduled at 12 months. Conclusions: In dominant-hemisphere tandem MCA disease, staged, perforator-sparing clip reconstruction can restore physiologic branch and perforator behavior while avoiding prolonged antiplatelet exposure and device-related branch uncertainty. A future-facing pathway pairs subtle clinical latency metrics with high-fidelity angiography, reports outcomes in branch- and perforator-centric terms, and, where available, incorporates patient-specific hemodynamic simulation and noninvasive lumen surveillance to guide timing, technique, and follow-up. Full article

Background/Objectives: Cancer patients using implanted venous access devices (ICVADs) for chemotherapy are at increased risk of venous thromboembolism (VTE), but the performance of risk assessment models (RAMs) in this setting is understudied. This study evaluated VTE incidence, risk factors, and the predictive performance of the Khorana, COMPASS-CAT, and ONKOTEV models. Methods: We retrospectively reviewed records of adult cancer patients treated with chemotherapy via ICVADs. The cumulative incidence (CI) of VTEs was estimated using the Fine–Gray method, and RAM performance was assessed by sensitivity, specificity, predictive values, accuracy, and AUC. Overall survival (OS) was analyzed using Kaplan–Meier and log-rank tests. Results: A total of 446 patients were included. The most common cancers were colorectal (29.6%), gastric (26%), pancreatic (18.4%), and breast (13.9%). During a median follow-up of 16.5 months, VTEs occurred in 82 patients (18.4%), including 43 (9.6%) that were ICVAD-related. Median time to VTE was 117 days and 68 days for ICVAD-related events. The CI of VTEs was 9% at 1 year and 18.4% at 2 years. ONKOTEV showed the best performance (accuracy of 74.4%, specificity of 85.7%, and AUC of 0.607), with 1-year incidence higher in the high-risk group (28.5% vs. 12.4%, p < 0.001). In contrast, all RAMs showed limited ability for ICVAD-related VTEs. VTE was independently associated with inferior OS (HR 1.39, p = 0.037). Conclusions: Cancer patients with ICVADs face a substantial risk of early VTEs. Among evaluated RAMs, ONKOTEV performed best for overall but not ICVAD-related events. Prospective studies are needed to guide prophylaxis strategies using validated RAMs. 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: Venous thromboembolism (VTE) is a serious and common complication in cancer patients, and it is the second leading cause of death after cancer itself. Cancer-associated thrombosis (CAT) is an indicator of a poorer prognosis and can lead to treatment delays and increased healthcare costs. This review aims to provide a comprehensive update on the efficacy and safety of tinzaparin in the treatment and prophylaxis of VTE in cancer patients. Methods: This is a narrative review that examines the pharmacological properties of tinzaparin, as well as the results from clinical studies and meta-analyses. It includes a discussion of tinzaparin’s role in special patient populations and its comparison with other anticoagulants. Results: Tinzaparin is a low-molecular-weight heparin (LMWH) that does not accumulate in patients with renal insufficiency, eliminating the need for dose adjustments. Studies have shown that tinzaparin is a safe and effective treatment for CAT, with a favorable safety profile regarding hemorrhagic complications. In the CATCH study, tinzaparin showed a significant reduction in clinically relevant non-major bleeding compared to warfarin. Tinzaparin has also been shown to be more effective than vitamin K antagonists (VKAs) in promoting the recanalization of venous thrombi. A meta-analysis confirmed that tinzaparin was superior to VKAs in preventing VTE recurrence in the long term. Conclusions: While direct oral anticoagulants (DOACs) offer convenience, LMWHs like tinzaparin remain crucial, especially for patients with specific characteristics such as renal insufficiency, complex drug interactions, or a high risk of gastrointestinal bleeding. Tinzaparin’s favorable safety and efficacy, along with its unique pharmacological properties, make it a valuable option for managing VTE in the complex oncology population. Full article

Background: Total knee arthroplasty (TKA) has evolved significantly, yet achieving consistently optimal outcomes remains challenging across diverse patient populations. This comprehensive narrative review identifies evidence-based “game changers” that genuinely transform TKA success while distinguishing them from interventions lacking clinical superiority. The analysis organizes findings across three perioperative phases: preoperative optimization, intraoperative techniques, and postoperative management. Preoperative game changers include end-stage bone-on-bone osteoarthritis, preoperative medical optimization of patients performed by dedicated practitioners, cryocompression therapy, and perioperative dexamethasone administration. Intraoperative interventions demonstrating substantial impact encompass reduced surgical time and optimized surgical instrumentation, personalized alignment, medial congruent bearings, cementless implants for high-demanding and high-BMI patients, and perioperative tranexamic acid. Postoperative game changers include early mobilization following surgery, venous thrombo-embolic prophylaxis avoiding high-bleeding-risk pharmaceuticals, and multimodal pain management. The review also identifies those initial promises without established clinical advantages, or “fake game changers”, that consume resources without meaningful benefits. This evidence synthesis demonstrates that TKA optimization requires systematic implementation of validated interventions rather than pursuing technological innovations indiscriminately. The future of TKA lies in evidence-based adoption of proven strategies that translate to genuine patient outcome improvements rather than merely increasing procedural complexity. Full article

Systemic or localized infections increase the risk of venous thromboembolism (VTE). All types of infection can elevate the risk of VTE thrombosis, although some appear to increase risk more than others. In the current narrative review, we seek to overview the available evidence related to the epidemiology of VTE caused by infections. We focused on patients with infection in community setting or hospitalized, on patients with COVID-19, HIV infection, tuberculosis, HCV infection, and CMV infection, as well as on individuals with other types of infection that might increase the risk of VTE. Moreover, we tried to evaluate how the risk of VTE in person with different types of infections could be addressed in clinical practice with the use of anticoagulants. Extended VTE prophylaxis may not be warranted for all infections, but may be very helpful for some, such as those with intra-abdominal infection, systemic bloodstream infection, lower respiratory infection, and symptomatic urinary tract infection. Full article