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Introduction: Prothrombotic is considered a condition that leads to the development of venous or arterial thrombosis and its consequences. There are many factors that cause a violation of the hemostatic potential in patients undergoing surgery with existing risk factors for thromboembolism, a more detailed study of the blood coagulation system, including the study of the compensatory capabilities of the hemocoagulation system, should be conducted. One of these methods is a functional test with double local hypoxia of the upper limb (DLHUL) under the control of thromboelastography (TEG). Goals: The purpose of the study - to identify the degree of thrombotic risk in patients preparing for planned surgical intervention, who belong to the risk group of thrombotic complications, to compare and evaluate the state of the hemostasis system in healthy volunteers and in this cohort of patients using a functional test with double local hypoxia of the upper limb by the method of thromboelastography. Materials and methods: A randomized prospective study was conducted. Patients were divided into two groups depending on the presence of risk factors for thrombosis. Group 1 consisted of healthy volunteers (n = 40) who are not at risk of thrombosis. Group 2 includes patients with existing factors of thrombotic risk (n = 120) who are preparing for scheduled surgical interventions. These patients underwent a functional test of "double local hypoxia of the upper limb" (DLHUL) using thromboelastographic (TEG) methods of studying the hemocoagulation system. The main task of this functional test is to create a trigger component to determine the limits of hemostasis, the origin and duration of adaptive and compensatory reactions of the hemostasis system. Indicators of the hemostasis system are recorded using a thromboelastograph before and after the test. The links of hemostasis are reflected by the following indicators: aggregate state of blood (A0), contact coagulation intensity (CCI), coagulation drive intensity (ICD), maximum clot density - maximum activity (MA), fibrinolytic activity - clot retraction and lysis index (IRCL). The results. Analyzing the data of thromboelastography after performing DLHUL, among the patients of Group 1, two types of reaction of the hemostasis system were found in patients without predictors of thrombotic risk: compensated (n= 20) (characterized by a decrease in the indicators of the vascular-platelet component; subcompensated (n = 20) (characterized by an increase in the indicators of the vascular -platelet component). In subjects of Group 1, TEG indicators indicate an increase in the external mechanism of prothrombinase formation, and the reaction of the procoagulant link of the blood coagulation system in response to the influence of a trigger indicates a change in the directionality of the hemostatic potential towards hypercoagulation. In subjects of group 1 with a compensated type, there is an increase in the components of fibrinolysis and a deviation of the hemostatic potential towards hypocoagulation is observed. The state of the hemostasis system in patients of Group 2 is characterized by pronounced changes in the hemostatic potential in all links. In the vascular-platelet link, a violation of platelet aggregation was noted, with an increase in indicators in response to a stimulus. When conducting the DLHUL test in the subjects of group 2, a decompensated (n = 98) and exhausted (n = 22) type of reaction to the test with local hypoxia of the upper limb was determined. That is, with increased platelet aggregation, hypercoagulation, inhibition of the anticoagulant system and fibrinolysis before the action of the trigger factor, after performing the DLHUL test, these disorders in the hemostasis system progress towards hypercoagulation, which is indicated by the increase in platelet aggregation, the strengthening of the coagulation link of the hemostatic system, the depression of fibrinolysis increases . However, the intensity of these changes is not as high as in patients of group 1 after the DLHUL test. Conclusions: The test with double local hypoxia of the upper limb is effective as a trigger factor to determine the compensatory capabilities of the HS. Depending on the type of reaction of the platelet-vascular, coagulation components of hemostasis and fibrinolysis to the influence of the trigger, two types of reaction of the blood aggregate state regulation system are possible in people who do not have an anamnesis of factors provoking a hypercoagulable state: compensated and subcompensated. Therefore, when planning surgical intervention in this cohort of patients, the risk of thrombotic complications is low. Depending on the type of reaction of the platelet-vascular, coagulation components of hemostasis and fibrinolysis to the influence of the trigger, two types of reaction of the blood aggregate state regulation system are possible in people with an anamnesis of factors provoking a hypercoagulable state: decompensated (more often) and depleted (less often). Patients with a history of factors provoking a hypercoagulable state have a high risk of perioperative thrombotic complications and a possible risk of thrombo-hemorrhagic complications, including the syndrome of disseminated intravascular coagulation. Changes in all links of the hemostasis system in response to the DLHUL test indicate the need to use anticoagulant therapy in patients with an anamnesis of factors provoking a hypercoagulable state as one of the components of preoperative preparation.

Introduction: There is no generalised consensus regarding perioperative prophylaxis of venous thromboembolism (VTE), either on using or timing it in patients undergoing spine surgery. VTE is a current concern because, even though being an uncommon event, it can cause serious complications. The aim of the present study is to propose guidelines for the prevention of thrombotic events in posterior spinal surgery, either as deep vein thrombosis or pulmonary thromboembolism. If the number of patients getting prophylaxis drugs is reduced a subsequent reduction of the incidence of epidural haematoma can be expected., Materials and Methods: A number of 235 patients who had undergone posterior spinal arthrodesis in the previous five years were studied. Mechanical thromboprophylaxis measures consisting of compression stockings were applied in all of them. Anticoagulant drugs were also applied whenever risk factors for thrombosis were observed. Early weight-bearing was resumed immediately after surgery. Demographic, clinical, and surgical variables were collected, as well as complications appearing during the follow-up period, that was scheduled at one, two, four, six and twelve months after the surgery. Thrombotic events, if present, were diagnosed by clinical and imaging tests such as ultrasound and CT angiography., Results: From the total 235 patients of this series, one hundred and fifty-three cases met the study inclusion criteria. A total of four thrombotic events appeared, one in the form of deep vein thrombosis and other three in the form of pulmonary thromboembolism. These last patients suffering an embolism died because of it. None of the variables studied had statistical significance for the occurrence of a thrombotic event. All four patients who suffered thrombotic events were receiving anticoagulant drugs, in addition to mechanical compression stockings, because of the presence of risk factors for thrombosis., Conclusions: By applying the fore mentioned protocol, adequate prevention of thromboembolic events was achieved in this study population of patients undergoing posterior spinal surgery., (Copyright © 2024 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.)

Aim: This study aims to analyze trends in venous thromboembolism (VTE) mortality in the Spanish Autonomous Communities (ACs) from 1999 to 2022, with a focus on identifying regional disparities and informing targeted public health interventions., Methods: Age-standardized mortality rates (ASMRs) were calculated using the European standard population as a reference. Joinpoint regression analysis was employed to identify significant changes in mortality trends, and geographical analysis was conducted using Bayesian inference to assess regional variations in mortality risk., Results: From 1999 to 2022, Spain recorded 59,515 VTE-related deaths, with a higher proportion in women (59.4%) compared to men (40.6%). On a nationwide scale, VTE ASMRs showed a general decline for both men and women, with rates decreasing from 11.0 to 5.1 per 100,000 in men and from 9.2 to 4.4 per 100,000 in women. However, this decline was not uniform across all regions or demographic groups. Notably, mortality rates among younger individuals, particularly men, increased during the study period, highlighting the need for targeted interventions. Analysis revealed significant regional disparities, with higher mortality risks observed in Extremadura, Aragon, Navarre, and Andalusia, particularly for women., Conclusions: This study provides valuable insights into the complex landscape of VTE mortality in Spain. While the overall decline in mortality is encouraging, persistent regional disparities and rising rates among younger individuals underscore the need for ongoing surveillance and targeted interventions., (Copyright © 2024. Published by Elsevier España, S.L.U.)

Venous thromboembolism is undoubtedly one of the frequent and dangerous complications after orthopedic surgery. If not detected in time, it can lead to very serious consequences concerning the patient's health and life. Therefore, it is crucial to know the risk factors for thromboembolic incidents. Among these factors, we can distinguish those related to the patient, his or her health status, lifestyle and factors that depend on the type of orthopedic intervention performed. Each patient should undergo an individual assessment of risk factors before undergoing surgery. Undoubtedly, an important role is played by observing the patient to detect early and late symptoms, as well as appropriate care in the postoperative period to reduce the risk of thromboembolic incidents. It is important to catch the disease at an early stage and undertake appropriate diagnostics to exclude or confirm the disease. The risk of venous thromboembolism can be lowered by using thromboprophylaxis. Various forms of prevention are available, which include various methods and means of prevention. An appropriate approach to the problem of the occurrence of this type of complication after orthopedic surgery affects not only the results of the treatment of orthopedic conditions, but also the overall health and functioning of the patient and his prognosis.

The formation of a thrombus in a vein leads to a narrowing of its lumen and a reduction in blood flow, which results in the development of venous thromboembolism (VTE). It manifests itself in most cases, including pain, swelling and redness of the affected limb. Data published in 2007 indicate that in 6 European Union countries as many as 370,000 deaths per year are a consequence of deep vein thrombosis (DVT), which is 75% a consequence of hospitalization. [2] [11] The causes of blood clots are found in the factors of the so-called Virchow triad. The main risk factors for venous thromboembolism as well as its complications of pulmonary embolism include thrombophilia, advanced age, previous VTE, immobilization of trauma or surgery. In the diagnosis of VTE, the determination of D-dimer level plays a key role.

Objective We aim to evaluate factors associated with the recurrence of thromboembolic episodes among patients with a first episode of venous thromboembolic disease during anticoagulation treatment and at least one year after treatment suspension. Methods A prospective cohort of patients with a first episode of deep vein thrombosis confirmed by Doppler ultrasound and initiated anticoagulation treatment. Participants were registered in the Institutional Registry of Thromboembolic Disease between June 2015 and March 2019. Patients with cancer, with permanent inferior vena cava filter implant, and those who refused to participate or did not provide informed consent were excluded. All patients were evaluated within treatment at 30 days and at least one year after the suspension of anticoagulation with a D-dimer study and an ultrasound. All patients were evaluated for recurrence, bleeding (major and minor), and death. Results A total of 304 patients were recruited during the study period. Seventy-three percent were female, and the median age was 80 years. The rate of recurrence rate during anticoagulation treatment was 5% (N = 16/303; 95% confidence interval: 3 to 8), and 5% during post-suspension follow-up (N = 11/202; 95%CI: 3 to 9). The overall bleeding rate was 13% (N = 39; 95%CI: 9 to 17), and 5% for major bleeding. Patients who recurred had higher basal D-dimer mean, higher neutrophils and monocytes, and a higher prevalence of age-adjusted D-dimer ratio greater than 0.5 before discontinuation. In addition, they more frequently had complete leg involvement by ultrasound and received a shorter treatment. Conclusions Although some baseline and pre-suspension parameters had a higher recurrence incidence, statistical significance was not reached, probably due to small statistical power and a short-term follow-up.

Introduction and purpose: Pulmonary embolism (PE) is one of the leading causes of death worldwide. There are many factors that increase the risk of its occurence. High costs of treatment, non-specific symptoms and high mortality of the disease determine the further search for new methods of treatment and diagnostics. The aim of the study is to determine the incidence of PE in patients after fracture of the proximal end of the humerus. Materials and methods: A literature search was conducted in the PubMed MEDLINE database of medical publications using the following keywords: pulmonary embolism, deep vein thrombosis, proximal humerus fracture. Results: Among the found articles, 4 original papers describing the problems of pulmonary embolism after fractures of the proximal end of the humerus were qualified for further analysis. The incidence of PE after this type of fracture is rare and ranges from 1.3% to 5.1%. Moreover, PE was not the cause of death of any patient in the analyzed literature. Conclusion: The need for further randomized controlled trials on a large group of patients operated with the same technique was demonstrated, including subgroups with and without antithrombotic chemoprophylaxis.

Pulmonary embolism is occlusion of one or more pulmonary artery . Deep vein thrombosis is responsible for most cases of PE. Pulmonary embolism is in 50% cases asymptomatic. Risk factors are: surgery, trauma, venous catethers, superficial vein thrombosis,, immobilization, obesity, policythemia vera, infection, cancer, hormonal contraceptives. The aim of this paper is to present available diagnostic tools and treatment method of pulmonary embolism. Nowadays, there are many tools, such as ECG, laboratory markers or imaging technique, which help us in diagnosis of pulmonary embolism. They consist of: ECG, laboratory markers and imaging techniques. D-dimer are standard laboratory test in diagnosis of PE. D-dimer has high diagnostic sensivity and is usually used to exlude PE. Ultrasonography is also useful for detection of PE. Ultrasound is non-invasive technique, which can be performed by the bed or during surgery. More advanced techniques of imaging, such as ventilation-perfusion scan or computed tomography pulmonary angiogram (CPTA) are also used in diagnosis of pulmonary embolism. Method of treatment depends on patients state and comorbidities: anticoagulation, thrombolysis, surgical embolectomy and cathether-directed thrombolysis, Pulmonary embolism is often diagnosis of exclusion. Nowadays, with development of imaging techniques and laboratory tests, diagnosis of PE and proper treatment may be implemented quickly.

Introduction: Deep vein thrombosis (DVT) is a condition in which a blood clot forms in one of the body's deep veins, most commonly of the leg or pelvis. Before the fourth decade of life risk of DVT is low (about 1 per 10000). After the age of 45, it rises and approaches about 5 per 1000 by the age of 80. Noteworthy is the fact, that patients with a positive family history have a higher risk of DVT at a young age. Essential risk factors for developing DVT are genetic conditions or acquired thrombophilia and positive family history, but the lack of family predisposition cannot rule out the occurrence of DVT. Standard treatment method of DVT involves intravenous anticoagulation with the use of low molecular weight heparin and compression therapy. Apart from the above-mentioned methods, we can distinguish intermittent pneumatic compression, surgical embolectomy, pharmacomechanical thrombectomy, and venous stenting. Case Report: We present a case report of 19 - year old patient who was first admitted to hospital in April 2017 urgently with symptoms of pulmonary embolism which was confirmed in angio-CT. Moreover, in the Doppler ultrasound, left common iliac vein (LCIV), left external iliac vein (LEIV) and left femoral vein (LFV) thrombosis was diagnosed. During the hospitalization, genetic tests, antibody levels, and antithrombin levels were performed for thrombophilia and systemic diseases conducive to thrombosis. In October 2017 the angio-MR of the pelvis confirmed visible pressure on the LCIV, caused by the common iliac artery, which corresponds to the May-Turner syndrome. In March 2018 he was admitted to the clinic with DVT symptoms of the left lower limb such as swelling, pain, and redness. The patient underwent venous angioplasty and stent implantation for LCIV. The patient was discharged from hospital with recommendations such as compression therapy, Doppler ultrasonography and monitoring of INR. Discussion: Venous thrombosis is a multicausal disease: more than one risk factor needs to be present before thrombosis occurs. Choice of DVT treatment method is aimed at improving the quality of life of patients depending on clinical symptoms. venous stenting for an iliofemoral occlusive disease is a safe and effective method of treatment. It can be done with excellent patency rates expected in cases of idiopathic occlusion and May-Thurner syndrome. On this basis, the legitimacy of using venous stent implantation as an effective method of treatment of recurrent DVT episodes can be confirmed, which has been used in the described case.

Introduction: The aim of this study was to evaluate the efficacy of aspirin versus low molecular weight heparins (LMWH) for the prophylaxis of venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing total knee arthroplasty (TKA) and/or total hip arthroplasty (THA)., Materials and Methods: Systematic review and meta-analysis. Sixteen studies were selected. The risk of VTE, DVT and PE were analyzed. Mortality, risk of bleeding and surgical wound complications was also analyzed., Results: 248,461 patients were included. 176,406 patients with thromboprophylaxis with LMWH and 72,055 patients with aspirin thromboprophylaxis. There were no significant differences in the risk of VTE (OR = 0.93; 95% CI: 0.69-1.26; P = .64), DVT (OR = 0.72; 95% CI: 0.43-1.20; P = .21) or PE (OR = 1.13; 95% CI: 0.86-1.49; P = .38) between both groups. No significant differences were found in mortality (P = .30), bleeding (P = .22), or complications in the surgical wound (P = .85) between both groups. These same findings were found in the sub-analysis of only randomized clinical trials (P>.05)., Conclusions: No increased risk of PE, DVT, or VTE was found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis. There was also no greater mortality, greater bleeding, or greater complications in the surgical wound found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis., (Copyright © 2023 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: The aim of this study was to evaluate the efficacy of aspirin versus low molecular weight heparins (LMWH) for the prophylaxis of venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing total knee arthroplasty (TKA) and/or total hip arthroplasty (THA)., Materials and Methods: Systematic review and meta-analysis. Sixteen studies were selected. The risk of VTE, DVT and PE were analysed. Mortality, risk of bleeding and surgical wound complications was also analysed., Results: 248,461 patients were included. 176,406 patients with thromboprophylaxis with LMWH and 72,055 patients with aspirin thromboprophylaxis. There were no significant differences in the risk of VTE (OR=0.93; 95% CI: 0.69-1.26; p=0.64), DVT (OR=0.72; 95% CI: 0.43-1.20; p=0.21) or PE (OR=1.13; 95% CI: 0.86-1.49; p=0.38) between both groups. No significant differences were found in mortality (p=0.30), bleeding (p=0.22), or complications in the surgical wound (p=0.85) between both groups. These same findings were found in the sub-analysis of only randomised clinical trials (p>0.05)., Conclusions: No increased risk of PE, DVT, or VTE was found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis. There was also no greater mortality, greater bleeding, or greater complications in the surgical wound found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis., (Copyright © 2023 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: In high-risk patients, common prophylaxis may be insufficient to prevent thromboembolic events after orthopaedic procedures. In this scenario, a retrievable vena cava filter (VCF) could be considered as an alternative, although it's use remains controversial. Therefore, we asked: (1) what is the overall mechanical complication rate associated with the use of retrievable VCFs in orthopaedic surgery?, (2) what is the association with thromboembolic disease (TED) recurrence, post-thrombotic syndrome and/or major bleeding according to different surgical characteristics?, (3) What is the overall mortality rate attributed to VCF use?Methods: We retrospectively analyzed a cohort of 68 patients who underwent orthopaedic surgery with a previous diagnosis of TED, in whom a retrievable VCF was placed. Permanent filters were excluded. We studied the filter’s mechanical complications and considered as possible outcomes death and 3 hematologic complications: TED recurrence, post-thrombotic syndrome and major bleeding. To estimate association with risk factors, we subclassified surgeries into 5 groups: 1, arthroplasty/non-arthroplasty; 2, primary/revision; 3, elective/urgent; 4, oncologic/non-oncologic; 5, preoperative/postoperative filter.Results: Mechanical complications were 16% and required a filter revision. Sixty-four percent of the revised VCFs developed a mechanical failure and could not be retrieved. Overall prevalence of TED recurrence, post-thrombotic syndrome and hemorrhage was 33%, 15% and 4.5%, respectively. Spinal surgeries were a risk factor for developing TED recurrences. Only 4% of patients died of a TED recurrence.Conclusions: Orthopaedic procedures had a high risk of mechanical and hematologic complications after using a retrievable VCF. However, mortality was low due to these complications.

Objective: Cost-effectiveness analysis of a 6-month treatment of apixaban (10 mg/12h, first 7 days; 5 mg/12h afterwards) for the treatment of the first event of venous thromboembolism (VTE) and prevention of recurrences, versus low-molecular-weight heparins/vitamin K antagonists treatment (LMWH/VKA). Material and methods: A lifetime Markov model with 13 health states was used for describing the course of the disease. Efficacy and safety data were obtained from AMPLIFY and AMPLIFY-EXT clinical trials; health outcomes were measured as life years gained (LYG) and quality-adjusted life years (QALY). The chosen perspective of this analysis has been the Spanish National Health System (NHS). Drugs, management of VTE and complications costs were obtained from several Spanish data sources (€, 2014). A 3% discount rate was applied to health outcomes and costs. Univariate and probabilistic sensitivity analyses (SA) were performed in order to assess the robustness of the results. Results: Apixaban was the most effective therapy with 7.182 LYG and 5.865 QALY, versus 7.160 LYG and 5.838 QALYs with LMWH/VKA. Furthermore, apixaban had a lower total cost (€13,374.70 vs €13,738.30). Probabilistic SA confirmed dominance of apixaban (led to better health outcomes with less associated costs) in 89% of the simulations. Conclusions: Apixaban 5 mg/12h versus LMWH/VKA was an efficient therapeutic strategy for the treatment and prevention of recurrences of VTE from the NHS perspective.

Justificación y Objetivo: Analizar la farmacoterapéutica empleada con las heparinas de bajo peso molecular (HBPM) prescritas en pacientes hospitalizados en el Hospital Clínica Bíblica (hospital privado en Costa Rica) con base en los lineamientos establecidos por el Colegio Americano de Cirujanos Torácicos (2008). Material y métodos: En el presente estudiose incluyeron pacientes internados en el período marzo-agosto 2010 que fueron tratados con HBPM.De esta población se analizaron 250 pacientes elegidos de forma aleatoria según la metodología recomendada. Se recopilaron todos los documentos e información necesaria de cada paciente para el correspondiente análisis. Resultados: Un 43% del total de pacientes hospitalizados utilizaron HBPM (707 pacientes). En un 91% de los casos, las HBPM fueron utilizadas con un fin profiláctico. Solamente un 2% de los pacientes que utilizaron HBPM de manera profiláctica no necesitaban de la misma. En un 90% de los casos, la dosis utilizada fue correcta. En un 18% de los casos se requería un ajuste de dosis. Un 80% de los casos presentó algún tipo de interacción farmacológica de relevancia clínica. Un 4% de los pacientes presentaron algún tipo de hemorragia, en donde un 2% de los casos este efecto estaba ligado al uso de HBPM. El 9% de los casos en los que se utilizaron las HBPM como tratamiento, fueron abordados según los lineamientos. Conclusión: En el Hospital Clínica Bíblica, el uso las HBPM se apegó a las recomendaciones establecidas por la normativa de la ACCP, a pesar de la no existencia en ese momento de un protocolo en el hospital. El análisis farmacoterapéutico por parte del farmacéutico clínico, puede suministrar información importante al médico para que se tomen las medidas correctivas y/o preventivas asociadas a la correcta utilización de estos medicamentos. Realizar una correcta estratificación de riesgo e individualización del tratamiento facilita la implementación adecuada de la farmacoterapia con HBPM en este hospital, donde existe una alta proporción de pacientes que pueden desarrollar eventos tromboembólicos.Aim: To analyze the prescription of low molecular weight heparins in hospitalized patients at the Clinica Biblica Hospital (private hospital in Costa Rica) based on the guidelines established by the American College of Chest Physicians (ACCP;2008). Material and methods: This study included 1651 hospitalized patients in the period from March to August 2010 who were treated with low molecular weight heparins, 250 patients were analyzed and randomly selected. A compilation of documents and information required for each patient for the analysis was made. Results: A total of 43% of the hospitalized patients used low molecular weight heparins (707 patients). In 91% of cases low molecular weight heparins were used with a prophylactic purpose. 2% of patients did not need to use prophylactic heparin therapy. In 90% of cases the dose was correct. 18% of cases required dose adjustments. In 80% of the patients had clinically relevant drug interactions, 4% of patients had some form of bleeding, where 2% of cases this effect was linked to the use of low molecular weight heparins. In 9% of cases in which LMWH were used as treatment were addressed in accordance with established guidelines. Conclusion: In the Hospital Clinica Biblica low molecular weight heparins were used according to the recommendations established by the guidelines of the ACCP despite the non-existence at the time of a hospital protocol. A pharmacotherapeutic analysis by the clinical pharmacist can provide important information to the medical doctor in order to take corrective and / or preventive actions associated with the correct use of medications. Make correct risk stratification and individualization of treatment facilitates proper implementation of drug therapy with low molecular weight heparins in this hospital where there is a high proportion of patients that may develop thromboembolic events.

Introduction: Recent surgery is a well-known major transient risk factor for venous thromboembolism (VTE) due to the low risk of VTE recurrence after anticoagulation is discontinued. On the other hand, the risk of VTE recurrence among patients with COVID-19-associated VTE is unknown. This study aimed to compare the risk of VTE recurrence between patients with COVID-19- and surgery-associated VTE., Methods: A prospective observational single-center study was performed including consecutive patients diagnosed with VTE in a tertiary hospital from January 2020 to May 2022 and followed up for at least 90 days. Baseline characteristics, clinical presentation, and outcomes were assessed. The incidence of VTE recurrence, bleeding, and death was compared between both groups., Results: A total of 344 patients were included in the study: 111 patients with surgery-associated VTE and 233 patients with COVID-19-associated VTE. Patients with COVID-19-associated VTE were more frequently men (65.7% vs 48.6%, p = 0.003). VTE recurrence was 3% among COVID-19 patients and 5.4% among surgical patients, with no significant differences ( p = 0.364). The incidence rate of recurrent VTE was 1.25 per 1000 person-months in COVID-19 patients and 2.29 person-months in surgical patients, without significant differences ( p = 0.29). In the multivariate analysis, COVID-19 was associated with higher mortality (HR 2.34; 95% CI 1.19-4.58), but not with a higher risk of recurrence (HR 0.52; 95% CI 0.17-1.61). No differences were found in recurrence in the multivariate competing risk analysis (SHR 0.82; 95% CI 0.40 - 2.05)., Conclusions: In patients with COVID-19 and surgery-associated VTE, the risk of recurrence was low, with no differences between both groups., (© 2023 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

JUSTIFICATIVA E OBJETIVOS: O tromboembolismo venoso (TEV), que inclui a trombose venosa profunda (TVP) e o tromboembolismo pulmonar (TEP) são complicações comuns em pacientes críticos. A ocorrência de TEV acarreta um substancial aumento da morbimortalidade dos pacientes internados em unidades de terapia intensiva (UTI). CONTEÚDO: A maioria dos pacientes críticos apresenta alto risco para ocorrência de complicações tromboembólicas, entretanto, a prevenção do TEV muitas vezes não é realizada de maneira adequada para este grupo de pacientes. A heparina de baixo peso molecular (HBPM) parece ser o método mais eficiente para a prevenção do TEV em pacientes de UTI. Entretanto, é patente a escassez de estudos voltados para esta população, cujas particularidades levam a recomendações específicas em relação ao diagnóstico e tratamento. CONCLUSÕES: Esta revisão faz uma análise do risco, discute os principais trabalhos publicados a respeito da profilaxia e sugere estratégias para a diminuição da ocorrência de TEV nos pacientes críticos.BACKGROUND AND OBJECTIVES: Venous thromboembolism (VTE), with includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common complication in critically ill patients, resulting in high morbidity and mortality. CONTENTS: Most patients treated in intensive care units (ICU) face a high risk of thromboembolic complications. Despite these considerations, the prevention of VTE may not be as high a priority in ICU patients as it is in other high-risk patient groups. Low molecular weight heparin (LMWH) may be the optimal prophylaxis in most ICU patients, but there is a lack of sufficient data including the paucity of VTE consensus and guidelines documents pertaining to critically ill patients. CONCLUSIONS: This article reviews background, current options, and recommendations regarding VTE in intensive care population emphasizing special diagnostic and treatment considerations in the ICU setting.

Introduction: D-dimer has a high negative predictive value for the diagnosis of venous thromboembolic disease (VTE). However, VTE has been reported in the presence of normal D-dimer values., Methods: This is a prospective observational study in patients with VTE from Hospital Gregorio Marañón between 2001 and 2022, comparing the characteristics of clinical presentation based on D-dimer levels (<500 ng/mL vs. ≥500 ng/mL)., Results: A total of 2582 patients were found, 333 patients (12.9%) presented negative or weakly positive D-dimer levels. They were significantly younger (57.9 vs. 65.3 years), with a lower prevalence of comorbidities (ischemic heart disease, dementia, and chronic kidney disease), and a greater family history of VTE (8.4% vs. 5.2%) and thrombophilia (11.7% vs. 7.8%). They presented significantly less dyspnea (57.6% vs. 75.4%), syncope (3% vs. 13.5%), less thrombotic load, elevated NT-pro-BNP (22.0% vs. 48.2%), and right ventricle dilatation (8.1% vs. 30.0%)., Conclusion: Patients with VTE and low D-dimer levels at diagnosis were younger, with milder clinical presentation and lower thrombotic load; but they presented a higher prevalence of thrombophilia and a family history of VTE., (Copyright © 2022 Elsevier España, S.L.U. All rights reserved.)

Background: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are both complications linked with COVID-19. Lower limb point-of-care clinical ultrasound (POCUS) could detect occult clots, helping decide whom to treat with anticoagulation., Objectives: To determine proximal DVT prevalence with POCUS screening among hospitalized COVID-19 patients., Patients/methods: Lower limb POCUS was performed in all patients admitted either to the ward or intensive care unit (ICU) between April 22nd and 30th 2020. Clinical and laboratory features, prescriptions, thrombotic complications and outcomes were assessed., Results: 87 patients were screened, of which 26 (29.8%) either had been discharged from ICU (19.5%) or were still in critical condition (10.3%). DVT was found in 4 patients (3 femoral, 1 popliteal), of which 1 had not received low molecular weight heparin (LMWH) prophylaxis. 21 CT pulmonary angiograms were performed, being positive for PE in 5 cases (23.8%); only 2 of these patients suffered DVT., Conclusions: Screening lower extremities with POCUS did not find a high rate of DVT among patients receiving LMWH-prophylaxis. However, there was a noteworthy amount of PE without DVT., (Copyright © 2021 Elsevier España, S.L.U. All rights reserved.)

Phlegmasia cerulea dolens (FCD) is a rare complication of deep vein thrombosis. Its cause is unknown. The main predisposing factors for the disease are neoformative processes, hypercoagulable states, congestive heart failure, pregnancy, prolonged immobilization, and surgeries on the affected limb. FCD is characterized by massive edema, severe pain, and cyanosis. The diagnosis is clinical. It is associated in most cases with pulmonary embolism and can lead to loss of the compromised limb if not treated in time. So far there is no consensus on its treatment. In clinical practice the use of anticoagulation with heparin, local thrombolysis, systemic fibrinolysis, surgical thrombectomy, fasciotomy, and inferior vena cava filter are described. In irreversible cases amputation is required. We present the case of a patient with FCD, the treatment performed and the evolution.

Objectives: To assess the 180-day prognosis for patients of different profiles diagnosed with venous thromboembolism (VTE) in emergency departments (EDs). Secondary aims were to assess all-cause mortality and readmission rates and to describe the clinical characteristics and forms of presentation of deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE) in each patient profile., Material and Methods: Secondary analysis of data from the ESPHERIA registry (Spanish acronym for Risk Profile of Patients with VTE Attended in Spanish Emergency Departments), which includes consecutive patients with symptomatic VTE treated in 53 EDs. The cases were divided according to 4 profiles: 1) unprovoked DVT, 2) DVT provoked by transient risk factors, 3)patients with cancer, and 4) patients with low cardiopulmonary reserve. The primary outcome was a composite of 180-day all-cause mortality or readmission., Results: We studied 773 patients: 450 (58.2%) were classified as profile 1, 128 (16.6%) as profile 2, 115 (14.9%) as profile 3 , a nd 8 0 ( 10.3%) a s p rofile 4. We fo und di fferences be tween th e 4 pr ofiles in demographics, com orbidity, clinical presentation, type of DVT and location, management, and outcomes. One hundred ninety-five p atients (25.2%) had at least one of the adverse events included in the composite within 180 days: 69 (8.9%) died and 179 (23.2%) were readmitted. Hazard ratios (HR) indicated that DVT with low cardiopulmonary reserve (HR, 1.73; 95% CI, 1.12-2.68; P = .01)) or DVT with cancer (HR, 3.10; 95% CI, 2.22-4.34; P .001) were the profiles t hat w ere independently associated with the 180-day composite outcome., Conclusion: Classifying patients with DVT according to 4 profiles ( unprovoked, provoked by t ransient r isk f actors, associated with cancer, and associated with low cardiopulmonary reserve) when making the diagnosis is useful for assessing prognosis for all-cause mortality or readmission within 180 days. This classification could be useful for establishing a care and follow-up plan when discharging patients with DVT from the ED.

Surgery increases the risk (by 20-fold) of venous thromboembolism (VTE), but there are prophylaxis methods (mechanical, pharmaceutical or combined) that safely reduce the incidence rate of VTE. The administration of prophylaxis requires a prior assessment of the risks associated with the patient and with the type of surgery. The Caprini and Rogers scales classify patients into four VTE risk categories (very low, low, moderate and high). In pharmacological prophylaxis, the risk of bleeding should also be assessed. At this time, the recommendation is to administer prophylaxis to all patients: mechanical prophylaxis for low, moderate or high risk with contraindications for the administration of heparin; combined with heparin for very high risk; and with drugs such as low-molecular-weight heparin, unfractionated heparin and fondaparinux for moderate to high risk. These measurements should be kept until full ambulation, discharge, or at least seven days (for major oncologic and bariatric surgery, maintain for four weeks)., (Copyright © 2020 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Deep vein thrombosis of the lower extremities is a common condition that should be treated appropriately given the possibility that it could lead to an ultimately fatal complication, as well as to a post-thrombotic syndrome that is in some cases disabling. The current treatment for this condition is differentiated into an acute phase, a long-term therapy and occasionally an extended therapy, which not only has defined objectives but also uses various drugs and even varying dosages for each drug. We describe the therapeutic anticoagulation options in each of these treatment phases and some of the treatments (thrombolysis, insertion of an inferior vena cava filter, surgery) that can play a role in certain conditions., (Copyright © 2020 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

The use of clinical ultrasonography has grown exponentially in the past decade in various medical settings. As with other areas of activity in the field of internal medicine, clinical ultrasonography has been implemented in venous thromboembolism disease, both in deep vein thrombosis and pulmonary embolism. In this review, we cover the diagnostic techniques, both for deep vein thrombosis through compression ultrasonography and for multiorgan ultrasonography, which include compression ultrasonography, pulmonary ultrasonography in the search for pulmonary infarctions and echocardiography for detecting dilation and right ventricular dysfunction for the diagnosis of pulmonary embolism. We also establish the most common clinical scenarios in which clinical ultrasonography can be of assistance in actual clinical practice, as well as its limitations and current evidence., (Copyright © 2019 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Objectives: To assess the accuracy, safety, and efficiency of ultrasound images obtained by emergency physician to diagnose deep vein thrombosis (DVT). patients with acute heart failure (AHF) attended in a hospital emergency department (ED)., Material and Methods: Prospective multicenter cohort study. We assigned patients suspected of having DVT to an intervention or control group. Emergency physicians took ultrasound images that were later evaluated by a radiologist in the intervention group. In the control group, images were evaluated only by the radiologist. We analyzed patient, physician, and episode variables. Test results, times until imaging, and 30-day adverse events were also analyzed. Sensitivity, specificity, positive and negative likelihood ratios, and agreement between physicians and radiologists (κ statistic) were calculated., Results: A total of 304 patients (209 in the intervention group and 95 controls) were included. The groups were comparable. The overall prevalence of DVT was 35.5% (95% CI, 30.3-41.0). The sensitivity of ultrasound images obtained by emergency physicians was superior in relation to experience: 71.4 (95% CI, 50.0-86.0) for those in a training course, 75.0 (95% CI, 80.0-95.4) for those with at least 2 months' practical experience, and 94.7 (95% CI, 82.7-98.5) for routine users. Specificity statistics for the 3 levels of physician experience were 83.3 (95% CI 55.2- 95.2), 100 (95% CI 83.0-100), and 96.6 (95% CI 88.4-99.0), respectively. The positive and negative likelihood ratios for ultrasound imaging by physicians were 27.94 and 0.054, respectively. The κ statistic was 0.80. Mean (SD) time until a physician took ultrasound images was 1.81 (1.46) hours versus 4.39 (1.81) hours until a radiologist obtained images (P = .007). Three deaths occurred within 30 days. They were not attributable to recurrence or bleeding., Conclusion: Ultrasound images taken by emergency physicians to diagnose DVT are accurate and safe and may be efficient. However, routine experience with ultrasound is necessary.

La enfermedad tromboembólica tiene altas cifras de morbilidad y mortalidad. Se presenta en un variado espectro de pacientes. Continúa siendo un diagnóstico importante en la atención de las urgencias médicas por lo que hemos decidido realizar esta revisión bibliográfica con el objetivo de actualizar los conocimientos cada vez más necesarios, sobre el diagnóstico y la conducta que se debe asumir en esos casos. Teniendo en cuenta que su diagnóstico por técnicas de imagen es cada vez más difícil, lo que evidencia el valor del método clínico en esta impactante enfermedad, así como su prevención. Sin olvidar que a pesar de estar estandarizada cada conducta, debe valorarse la individualidad del paciente.

Wünderlich syndrome, or spontaneous retroperitoneal hematoma, secondary to spontaneous rupture of the iliac vein is a rare clinical entity and a medical emergency. Often the aetiology is difficult to identify and different hypotheses have been proposed, such as the presence of hormonal, inflammatory and/or mechanical factors. It may be important to assess the presence of a factor that triggered the deep vein thrombosis and secondary rupture of the iliac vein and retroperitoneal hematoma. We present a case where venous thrombosis could have caused rupture of the iliac vein and we discuss the entity in light of the current literature., (Copyright © 2017 Sociedad Española de Anatomía Patológica. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objectives: To identify and prioritise indicators to assess the quality of care and safety of patients with non-valvular auricular fibrillation (NVAF) and deep vein thrombosis (DVT) treated with anticoagulants., Materials and Methods: Using the consensus conference technique, a group of professionals and clinical experts, the determining factors of the NVAF and DVT care process were identified, in order to define the quality and safety criteria. A proposal was made for indicators of quality and safety that were prioritised, taking into account a series of pre-established attributes. The selected indicators were classified into indicators of context, safety, action, and outcomes of the intervention in the patient., Results: A set of 114 health care and safety quality indicators were identified, of which 35 were prioritised: 15 for NVAF and 20 for DVT. About half (49%) of the indicators (40% for NVAF and 55% for DVT) applied to patient safety, and 26% (33% for NVAF and 20% for DVT) to the outcomes of interventions in the patient., Conclusions: The present work presents a set of agreed indicators by a group of expert professionals that can contribute to the improvement of the quality of care of patients with NVAF and DVT treated with anticoagulants., (Copyright © 2018 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.)

En: Deep vein thrombosis (DVT) and ruptured Baker's cyst have similar clinical presentations: inflammation and acute pain in the calf. Differential diagnosis is necessary and requires information from Doppler ultrasound imaging because treating suspected DVT with therapeutic doses of low molecular weight heparins (LMWHs) can cause major bleeding and worsen the prognosis of complicated Baker's cyst. We present a series of 7 consecutive cases in which the patients were misdiagnosed with DVT without imaging. LMWHs were started at therapeutic doses in all cases. The patients' symptoms worsened abruptly after treatment, causing compartment syndrome in the leg. Four of the patients required urgent fasciotomy.