Der Internist
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Several RNA-, vector-, and protein-based coronavirus disease 2019 (COVID-19) vaccines are currently available in order to achieve high titers of neutralizing antibodies against the spike protein as well as strongly activated CD4+- and CD+ T‑cells. However, there are formulation-specific advantages and disadvantages with regard to physicochemical stability, spectrum of adverse effects, need for adjuvants or adaptability to potentially novel viral variants. ⋯ As a consequence, innovative vaccines need to be developed for these patients. Undoubtedly, reports addressing, e.g. vaccine-associated myocarditis or thrombotic thrombocytopenia have led to uncertainties; however, vaccination remains the most important cornerstone in containing the pandemic.
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This review summarizes current evidence and guideline recommendations concerning diagnosis and treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE). For the diagnostic pathway, evidence-based algorithms should be employed, based on the assessment of pretest clinical probability. D‑dimer tests may reduce the need for subsequent diagnostic procedures. ⋯ In obese patients up to 150 kg, standard doses of rivaroxaban and apixaban are appropriate. In cancer-associated thromboembolism (CAT), the previous guideline recommendation to use low molecular weight heparin (LMWH) for 3-6 months is now broadened with the recommendation for factor Xa inhibitors, with the caveat for gastrointestinal and urothelial cancer or expected drug-drug interactions with the anticancer treatment. Here, and in unstable clinical situations, LMWH is preferred.
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Successful revascularization of patients with peripheral arterial disease (PAD) requires a comprehensive understanding of the risk population and the available treatment options. Even the urgency of revascularization varies widely depending on the clinical presentation. Patients with intermittent claudication should undergo a structured exercise program before revascularization may become necessary, whereas acute limb ischemia is a medical emergency and must be revascularized within a few hours. ⋯ The use of paclitaxel-coated balloons and stents has been shown to significantly reduce restenosis and reintervention rates after femoropopliteal interventions. However, a late mortality signal associated with the use of these devices continues to be debated. After successful intervention, appropriate drug therapy and standardized follow-up should be established to prevent adverse limb events and reduce the high rate of cardiovascular events.
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Patients with peripheral arterial disease (PAD) often have polyvascular atherosclerosis and are at increased risk of major adverse cardiovascular events (MACE), such as cardiovascular death, myocardial infarction or stroke, and major adverse limb events (MALE), such as amputation and acute limb ischemia. Therefore, the aim of conservative treatment is the reduction of MACE and MALE. In patients with intermittent claudication, the aim is also to extend walking distance. ⋯ Moreover, antithrombotic treatment should include antiplatelet therapy (acetyl salicylic acid 100 mg and clopidogrel 75 mg), and in patients at high thrombotic risk and low bleeding risk rivaroxaban 2 × 2.5 mg should be added. In patients with intermittent claudication exercise therapy is highly recommended. Despite the high risk, in particular patients with PAD are often undertreated in clinical practice.
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Venous disorders affect a large proportion of the German population (varicose veins 13.3%, chronic venous insufficiency 40.8%). ⋯ Superficial vein thrombosis of the legs requires comprehensive duplex ultrasonography of the superficial and deep leg veins. Only superficial vein thrombosis less than 5 cm in length and more than 3 cm from the saphenofemoral or saphenopopliteal junction can be treated conservatively with compression, cooling, and relative immobilization. Superficial vein thrombosis greater than 5 cm in length with more than 3 cm distance to the deep venous system is treated pharmacologically with fondaparinux for 45 days (approved for 30-45 days). If the surface thrombus reaches the saphenofemoral or saphenopopliteal junction at a distance of less than 3 cm, therapy analogous to deep vein thrombosis is required for 3 months. The most effective therapy for varicose veins is invasive removal. In this regard, endovenous thermal ablation has become particularly important in recent years, given that its effectiveness is of a similar order of magnitude to that of crossectomy and stripping surgery, but the complication rates are significantly lower. Invasive removal of varicose veins not only improves patients' quality of life, but also significantly reduces the risk of deep vein thrombosis. Recent epidemiological data demonstrate an increased risk of cardiovascular disease in patients with chronic venous insufficiency. There is preliminary evidence that this risk of cardiovascular disease in varicose vein patients can be lowered by varicose vein therapy.