Seminars in respiratory and critical care medicine
-
Semin Respir Crit Care Med · Feb 2008
ReviewThrombophilias: when should we test and how does it help?
Venous thromboembolism can be a life-threatening event, occurring in ~1 in 1000 adults annually. An underlying cause for thrombosis can now be identified in up to 80% of cases, including both inherited and acquired causes of thrombophilia. ⋯ This article reviews both the inherited and the acquired causes of thrombophilia, focusing on the clinical scenarios in which these disorders should be suspected and on how to appropriately test for them when clinically indicated. By the conclusion of this article, the clinician should be equipped with an algorithm of how to approach a patient with a thromboembolic event, from decisions regarding which thrombophilia tests to order to how the results of these tests affect patient management.
-
Semin Respir Crit Care Med · Feb 2008
ReviewInterventional approaches to acute venous thromboembolism.
During the last decade, advances in minimally invasive technologies have spurred a renaissance in the aggressive treatment of venous thromboembolism (VTE) using percutaneous techniques. In this article, we outline the relative risks and benefits of endovascular VTE therapies, highlight clinical situations in which the benefits of endovascular treatment are likely to outweigh its risks, and provide an update regarding the specific new modalities that may be applied to VTE. Pharmacomechanical thrombolysis represents the most promising currently available method to treat VTE. ⋯ At present, highly compromised patients with pulmonary emboli (PE) in whom systemic thrombolytic therapy has failed or is contraindicated are reasonable candidates for catheter-based PE interventions. Adjunctive pharmacomechanical catheter-directed deep venous thrombosis (DVT) thrombolysis is best indicated for the first-line treatment of patients with phlegmasia cerulea dolens, acute inferior vena cava (IVC) occlusion, and acute iliofemoral DVT after careful clinical assessment and a balanced discussion with the patient. It is hoped that multidisciplinary clinical trials with involvement by both interventionalists and pulmonary physicians will validate these techniques in the near future.
-
Massive pulmonary embolism (PE) with hemodynamic instability (e.g., hypotension and cardiac shock) is associated with a poor prognosis and high mortality rates (> 50%). Accordingly patients with massive PE should be treated aggressively with thrombolytic agents (or surgical or interventional procedures). Streptokinase, urokinase, and recombinant tissue plasminogen activator (rtPA) have been used, with generally similar results. ⋯ This article reviews indications for thrombolysis in massive PE, with an emphasis on recent data derived from normotensive patients. Further, we propose a diagnostic and therapeutic algorithm for treating acute PE. Additional studies are required to determine the benefit and safety of thrombolytic therapy for PE.
-
This review describes recent evidence relevant to the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE). Because venous thromboembolism (VTE) is a spectrum of disease that includes both of these disorders, many of the therapeutic options are common to both. At the time of diagnosis, effective treatment options for patients with VTE include unfractionated heparin, low molecular weight heparins (e.g., dalteparin, enoxaparin, tinzaparin), and pentasaccharides (e.g., fondaparinux). ⋯ Other treatment strategies such as vena caval filter placement and mechanical (or chemical) clot dissolution are discussed briefly. Anticoagulation with warfarin (or other oral vitamin K antagonists) is a highly effective strategy for the long-term prevention of VTE recurrence in most patients. In addition to presenting evidence relevant to the optimal duration of warfarin therapy, we highlight circumstances under which extended therapy with a parenteral agent such as a low molecular weight heparin might be preferable.