VASA. Zeitschrift für Gefässkrankheiten
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Thrombophilic defects have been shown to be associated with an increased risk of venous thrombosis, fetal loss, and gestational complications. The knowledge about the clinical relevance of thrombophilic defects is increasing, and evidence-based indications for thrombophilia screening are therefore discussed in this review. Selective thrombophilia screening based on previous personal and/or family history of venous thromboembolism is more cost-effective than universal screening in all patient groups evaluated. ⋯ Antithrombotic drugs like UFH, LMWH or low-dose aspirin may have a potential therapeutic benefit in patients with recurrent pregnancy loss and thrombophilia, but placebo-controlled, multicenter trials are urgently needed to clarify this issue. Although a supra-additive effect for the risk of venous thrombosis is observed between oral contraceptives and some thrombophilias, the absolute incidence of venous thromboembolism is low in premenopausal women and mass screening strategies are therefore unlikely to be effective. While antiphospholipid antibodies are known to be associated with arterial thrombosis, screening for heritable thrombophilias is not useful in arterial thrombosis, although subgroup analysis indicates that they may play a role particularly in young patients and children.
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Management of venous thromboembolism has long been characterized by a high degree of complexity and a disappointing lack of both efficacy and efficiency. The non-specific clinical signs of acute pulmonary embolism (PE) and the limitations of earlier imaging procedures such as the lung scan and pulmonary angiography led to the development of numerous sophisticated, multi-step diagnostic algorithms which, however, have proved extremely difficult to implement in clinical practice. As a result, the diagnosis of potentially life-threatening PE was frequently missed in many patients who subsequently died of the disease without receiving appropriate treatment, while other patients unnecessarily underwent a battery of invasive, time consuming procedures due to a vague, poorly documented clinical suspicion. ⋯ Furthermore, the importance of right ventricular (RV) dysfunction, even in the absence of overt hemodynamic instability, was recognized, and a number of studies demonstrated the value of echocardiography and laboratory biomarkers for risk stratification of PE. At present, low molecular weight heparins are increasingly becoming established as the treatment of choice for hemodynamically stable patients without RV dysfunction (non-massive PE), while consensus exists that patients with massive PE and cardiogenic shock necessitate emergency removal of pulmonary thrombus using thrombolytic agents, surgical embolectomy, or catheter-based thrombus aspiration. On the other hand, the treatment of stable patients with RV dysfunction (submassive PE) remains the subject of debate, and a large randomized trial is urgently needed to address the possible clinical benefits of thrombolysis in this setting.
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Ischemia/reperfusion-injury of skeletal muscle--pathophysiology and clinical implications. Ischemia and reperfusion of skeletal muscle occurs in acute vascular occlusion and revascularisation, in elective vascular surgery, in orthopedic surgery by means of a tourniquet, and in transplantation of muscle-containing cutaneous flaps. The ischemia sets up a cascade of events, which fully develops not prior to the moment of reperfusion. ⋯ The present review discusses the main mechanisms of ischemia/reperfusion-injury in terms of cellular metabolism, endothelial function, cytokine release, and leucocyte function. Release of toxic oxygen radicals by activated leucocytes plays the pivotal role in this reaction. In addition, the clinical manifestations of ischemia/reperfusion will be reviewed as well as some of the means proposed to control this harmful reaction.