Venous thrombosis in Cancer patients - are there any special features!

The risk of venous thrombosis is higher in cancer patients. But we do not know if there are specific features for the venous thrombosis in cancer patients. We believe that the thrombosis is dependent on the circulating procoagulant factors associated with or released by the cancer tissues. Is the proximal deep vein thrombosis  (iliac vein) more common in cancer patients? 

In a study conducted on - For 3263 patients with cancer, the venous thrombosis incidence was: total 31.4% (n=1026), proximal 14.5% (n=472), bilateral 8.5% (n=278) and multiple venous sites 4.6% (n=149). The rate of clinical suspicion of pulmonary embolism was 49.9% (n=1628). For 1026 patients withthrombosis, proximal thrombi were nearly as frequent as distal thrombi, with 17.6% (n=181) iliocaval thrombi. Gastrocnemial, popliteal and femoral veins were almost equally concerned by thrombosis with respective rates of 28.7% (n=278), 27.1% (n=294) and 25.6% (n=263). Superficial veins were concerned in 23.5% (n=241). Partial or floating clots occurred frequently in 4 localizations: common femoral, external iliac, femoral and popliteal veins. J Mal Vasc. 2013 Jun 18. pii: S0398-0499(13)00131-5. doi: 10.1016/j.jmv.2013.05.001. [Epub ahead of print]

This results of this study point out that - Proximal, multiple, partial, mobile thrombi, and such unusual locations as gastrocnemial or superficial thromboses, are potentially indicators for selecting patients that may benefit from a cancer check-up because their venous thrombosis could be due to cancer.

It may not be cost effective to screen all patients for cancer in our clinical practice - in addition to the above factors related to venous thrombosis, we should remember that recurrence of DVT requiring admissions ( 2 or 3 times) in last 6 months should also prompt us to think and investigate for the cryptogenic malignancies. We found this very useful in our clinical practice not to miss the hidden malignancies.  

30th June 2013

Will there be a role for Atorvastatin in acute deep vein thrombosis?

In the recent past it was observed that aspirin would be beneficial in the prevention of recurrent DVT and cardiovascular events if given as a secondary thromboprophylactic agent after initial anticoagulation. It was opined that this benefit of aspirin in the long run is due to the protection from the actions of cytokines circulating in the blood which seem to be higher in the group of patients. 
Can we consider that the statins such as Atorvastatin, Rosuvastatin are helpful in the acute DVT to protect the patients from effects of cytokines?
In a recent study it was observed that IL-6, IL-8, P selectin were reduced by the 3 day course of 40 mg of atorvastatin. Thromb Res. 2013 Jun 20. pii: S0049-3848(13)00183-7. doi: 10.1016/j.thromres.2013.04.026. [Epub ahead of print]
This  point needs to be studied further to determine role of statins in the acute deep vein thrombosis patients. If it is proved that we may be adding the statin to the heparin in the management of venous thromboembolism.

Can we patent Human Genes?

Superficial venous thrombosis (SVT)

Superficial vein thrombosis (SVT) is regarded a self-limiting disorder, although the authors of recent studies showed that ultrasonographically diagnosed SVT is a precursor for venous thrombosis. We would like to know whether the same holds true for clinically diagnosed SVT and to what extent it is associated with thrombophilia in a population-based case-control study (ie, Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis). 
It was found that a history of clinical SVT was associated with a 6.3-fold (95% confidence interval [CI] 5.0-8.0) increased risk of deep-vein thrombosis and a 3.9-fold (95% CI 3.0-5.1) increased risk of pulmonary embolism. Blood group non-O and factor V Leiden showed a small increase in SVT risk in controls, with odds ratios of 1.3 (95% CI 0.9-2.0) and 1.5 (95% CI 0.7-3.3), respectively. 

In conclusion, clinically diagnosed SVT was a risk factor for venous thrombosis. Given that thrombophilia was only weakly associated with SVT, it is likely that other factors (varicosis, obesity, stasis) also play a role in its etiology.

http://bloodjournal.hematologylibrary.org/content/118/15/4239.full?sid=78553d12-afe0-439a-bc3c-e96aa64324a1

"Hormonal contraception and venous thrombosis."

Background. New studies about the influence of hormonal contraception (HC) on the risk of venous thromboembolism (VTE) have been published. 

Material and methods. Studies assessing the risk of specific types of hormonal contraception were evaluated, compared and set into a clinical perspective. 

Results. The majority of newer studies have demonstrated a three fold increased risk of VTE in current users of middle- and low-dose combined oral contraceptives (COCs) with norethisterone, levonorgestrel or norgestimate compared with non-users. 

The same studies have demonstrated a six-fold increased risk of VTE in users of combined pills with desogestrel, gestodene, drospirenone or cyproteroneacetate, and in users of the contraceptive vaginal ring, compared with non-users. The rate ratio of VTE between COCs with newer progestogens as compared with users of COCs with levonorgestrel was 1.5-2.8 in seven and 1.0 in two studies. Progestogen-only contraception did not confer an increased risk of VTE in any study.

The incidence rate of VTE in non-pregnant non-HC using women 15-49 years is 4 per 10 000 years. 

Recommendations. For starters on hormonal contraception, we recommend middle or low-dose combined pills with norethisterone, levonorgestrel or norgestimate as 1(st) choice preparations. For the many women who are users of COCs with newer progestogens, although the absolute risk of VTE is low, a change to combined pills with norethisterone, levonorgestrel or norgestimate may half their risk of VTE. Finally, we recommend COCs with 20 μg estrogen combined with the older progestogens to be launched in the Scandinavian countries. Women at an increased risk of VTE should consider progestogen-only contraception or non-hormonal contraception.

DVT in Orthopedic and Abdominal surgery patients - is due to different types of pathophysiological changes?

Why should there be a difference in the incidence of DVT in Orthopedic and abdominal surgery patients in post operative period?

Lower preoperative fibrinolytic activation observed in patients undergoing orthopedic surgery compared with abdominal surgery might have pathophysiological consequences. This may explain why Without prophylaxis, patients subjected to major abdominal surgery have a risk of deep vein thrombosis of approximately 30%, while the rate varies between 40% and 60% in orthopedic surgery. Pinjala R K

http://link.springer.com/article/10.1007/BF02912463

Vein grafts are often used for bypassing the occluded arterial segments in diabetic people and those who are habituated to smoking. Thrombosis of the vein grafts occur in some patients though the veins look healthy from out side and it is often considered to be a technical problem and revision of the vein grafting is often done especially in peripheral vascular surgical patients. Hyperglycemia is known to effect the endothelial functions and endothelial derived relaxation is abnormal in the diabetic people to varying degrees depending on the exposure of the patient to the glycemic variability in the previous times. Now there seems to evidence to support that BMP-4 is probably responsible for this impaired EDR ( endothelium derived relaxations) which is not linked to cyclooxygenase-2 pathway.   

Can we develop specific ischemia resist muscle fibers in chronic stable ischemia people?

The answer to this question can solve some of the problems faced by lower limb ischemia patients who are not suitable for interventional therapies or after failure of all the existing therapies?

This year slogan on world health day is control your blood pressure. We are aware of the importance of controlling high blood pressure in people attending our outpatient clinics. This is chosen with an aim to prevent the morbidity and mortality associated with the hypertension related cardiovascular outcomes.
The governments should take notice of the importance of implementation of the blood pressure control programs and support them to see that blood pressure of the people at large is kept under control health education and also providing basic medicinal supplies to the people. Ideally it would be helpful to train more paramedical people record the blood pressure and register hypertensive patients e-register so, that necessary supports can reach them to prevent complications.
In our world 9 million death are attributed to the hypertension related complications. That means they are potentially preventable with active implementation of the antihypertensive programs.
from  Pinjala R K,  7th April 2013

AV grafting for Vascular Access

Newer Anticoagulants

Vascular lesions and Oral cavity bacteria

Buerger's disease progression after 60 years of age?

Buerger's disease vessel with thrombus in lumen

Buerger's disease is often seen in people who started  smoking tobacco early in their lives.   
Can we arrest this disease progression?

 It is known that people develop atherosclerosis if they had been smoking for a long time with classical plaque formation. We can expect them to develop the major cardiovascular events prematurely. It is in this aspect it would be interesting to know if these phenomena (MACE) are more common in the Buerger's disease patients during the follow up! There are very few papers published on long term survival and  the natural course of the disease. Takashi Ohta etal followed 110 patients for a mean follow up period of 10.6 years. Natural course of life and limb is favorable in many patients with TAO. The part of the disease which causes the necrotic lesions seems to be arrested in patients after 60 years of age. Early treatment and abstaining from smoking can certainly help in modifying the disease progression significantly.  Here, in our unit, Injection Prostaglandin E-1 infusion therapy ( 500 mcg  in 3 days/ once in a month injections ) over 6 months brought lot of relief to these patients and arrested the progress of the disease avoided the major amputations.

J Vasc Surg 2004;39:176-180   

Awareness of diabetic neuropathy in diabetics

Diabetic foot society of India 2012 lecture by Pinjala

DFSICON2012 7sept

Infected PTFE graft

Supra Renal Abdominal Aortic Aneurysms

Aortic aneurysms of the abdominal aorta are often seen in very sick patients in our clinics in public hospitals  Many times they are not suitable for the operations due to systemic problems. Endorepairs are expensive and they are not done in many public hospitals run by the governments. These are the images of the patient with symptomatic supra renal AAA involving the visceral branches. The aortic patch with all these branches was anastomosed to another graft from the main stem.  The aneurysm cavity shows the erosion of the vertebral bodies. The inter vertebral discs between the eroded vertebral bodies are seen in cavity. This is due to the late presentation of the patients which is common in people who are not able to get the interventions at an early stage. 

Endorepair of Aortic aneurysms, is it a failure?

Superglue and varicose veins

Carotid Endarterectomy

In India, carotid artery intervnetions are less often performed than coronary artery interventions. There are many reasons for the same. Carotid endarterectomy is also less often performed. In the elderly people there is tendency to consider angioplasty and stenting for carotid stenosis. But the studies are saying that the carotid endarterectomy is safer in the older people than the stenting. In a study published EJVES  it was shown that Carotid Endarterectomy was safer in the short-term than stenting, because of an increased risk of stroke associated with stenting in patients over the age of 70 years. Stenting should be avoided in older patients, but may be as safe as endarterectomy in younger patients.Determination of the efficacy and ultimate balance between the two procedures requiresfurther data on long-term stroke recurrence.

Eur J Vasc Endovasc Surg (2011) 41, 153e158

Happy new year 2013 to you. from Pinjala R K

Every year is new and we all look for betterment the next year. Change is inevitable and we all know that. But we want it to be our advantage. Well, some times yes but other times it is not. We need to ask for the strength to cope with the negatives and look the next year.

Clinical Medicine and medical education are rapidly changing with the progression of the internet science. We are going to see many more changes in this year 2013 with the introduction of the web2 or web 3, 4. Learner centric approach seems to be more appropriate and soon the typical class room teaching is going to take a back seat in all the medical colleges.  

Superior Mesenteric Artery Thrombosis

 Acute mesenteric ischemia is a rare. It is characterized by a high mortality rate. This may be associated with a variety of congenital prothrombotic disorders. A prompt diagnosis is a prerequisite for successful treatment. The treatment of choice remains laparotomy and thrombo-endarterectomy, although some prefer an endovascular approach.
A second-look laparotomy could be required to evaluate viable intestinal handles. we support a laparoscopic second-look. The possibility of evaluating the arteriotomy, during a repeated laparotomy with a Doppler ultrasound, is crucial to show a new thrombosis. Although the prognosis of acute mesenteric ischemia due to an acute arterial mesenteric thrombosis remains poor, a prompt diagnosis, aggressive surgical treatment and supportive intensive care unit could improve the outcome for patients with this condition.

Femoro-femoral Cross over Graft in leg ischemia

Femoro-femoral cross over graft in leg ischemia

Patients develop critical limb ischemia due to multi segmental disease or one or two segmental steno-occlusive lesions. We are now considering Endovascular therapies (angioplasty and stenting) or hybrid procedures for revascualarization of the lower limbs. Long segmental occlusions, failed iliac stenting patients ( occlusion) are occassionally considered for femoro-femoral bypass which is very useful in them. There is always a concern about the chances of infection if there is an ulcer in the foot or toes with infected groin lymphatics. The need for this operation is certainly decreased over period of time.

Happy new year 2013

Professor Pinjala Ramakrishna, MS.,FRCSEd.,FICS
Head of the department of Vascular surgery
Nizams's Institute of Medical Sciences
Hyderabad - AP, India 
Tel No 0091 40 3317115

Drug Eluting stents and disadvantages- can we overcome these?

Drug Eluting Stents for coronary arteries

The use of metal Drug Eluting Stents (DES) presents some potential drawbacks. These include a predisposition to late stent thrombosis, prevention of late vessel adaptive or expansive remodeling, hindrance of surgical re-vascularization, and impairment of imaging with multi slice CT. That means we need some thing better than this in future. Are we there yet? However, it has been hypothesized that stents placed in many atherosclerotic arteries may require only about 3–6 months of mechanical integrity for scaffolding. Bioabsorbable or biodegradable stents that provide mechanical support during vascular wall repair and then harmlessly erode after the vascular wall has stabilized may eliminate some of the potential chronic risks of permanent stents and may mitigate the complexity of repeat stenting at the same site in the event of restenosis.

Smart phone based Ultrasound device

Smart phone based ultrasound for bed side use

We  would like to get the diagnosis  in patients as early as possible with the use of small gadget. We would like to get all the information needed to take a decision or start a treatment. 

In the beginning stethoscope and knee hammer were useful to examine the patients with cardiovascular and neurological problems. In recent past after the emergence of CT and MRI scans they basic tools have fallen out of fashion. We are looking for new devices which are simpler but provide more crucial information on the bed side to change the medications or start new treatment. 

CME - Management of Varicose Veins and Venous Insufficiency

Varicose veins in both legs - marking on left side

Varicose veins are common as the age advances. Chronic venous disease presents with a spectrum of signs and symptoms, including cosmetic spider veins, asymptomatic varicosities, large painful varicose veins, edema, hyperpigmentation and lipodermatosclerosis of skin, and ulceration. But there is no definitive stepwise progression from spider veins to ulcers and, in fact, severe skin complications of varicose veins are not seen in some with extensive varicose veins.

1. Precipitating factor for varicose veins include 

A. nulligravida pregnancy status. 

B. normotension.  

C. prolonged standing. 

D. autosomal-recessive genotype with complete penetrance.

2. Symptoms of chronic venous insufficiency 

A. include swelling, restlessness, limb heaviness and fatigue, aching/throbbing sensation, burning, tingling, direct tenderness, itch, and nocturnal leg cramps. 

B. are usually worse at the beginning of the day. 

C. decrease during the menstrual cycle and in cold weather. 

D. are not relieved by elevation.

3. In varicose veins patients, what can compression stockings do?

A. control pain and edema.  

B. help patients lose weight. 

C. are most practical for patients who are elderly, are obese, or have skin damage. 

D. slow the progression of venous insufficiency.

4.  When there are cosmetic spider angiomas (≤3 mm) any of one these therapies - sclerotherapy, thermocoagulation, or cutaneous laser therapy will 

A. seldom necessitates more than 1 treatment. 

B. leads to complete resolution of varicosities in most patients.  

C. induces endothelial damage leading to venous thrombosis and fibrosis.  

D. All of the above

5. When high volumes of dilute local anesthetic is injected into a treatment area of VVs, it  is called 

A. truncal reflux.  

B. transilluminated powered phlebectomy.  

C. tumescent anesthesia. 

D. micronized purified flavonoid fraction. 

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 Answers

C,A,A,C,C

Govt funded Health Insurance schemes

Age, BMI determine the severity of chronic venous disease?

Age, body mass index and severity of primary chronic venous disease.

Chronic venous disease

The severity of CVI is linked with the age and BMI of the individuals. A study confirmed the relationship between age, CEAP clinical class and extent of the venous reflux severity of CVD. Older age means an increased number of insufficient venous segments and increased risk of the clinical progression of CVD from varicose veins to chronic venous insufficiency (C(3)-C(6), trophic skin changes and venous ulcers). The results in this study support the BMI, in term of frequency of venous reflux, as a risk factor in the whole group of patients but only in women but not in men. Multiple linear regression showed BMI together with age as significant predictors of clinical grade of CVD according to the CEAP classification. As regards the influence of BMI on clinical severity/grade of CVD, the results of our study support BMI as an important risk factor.  Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2011 Dec;155(4):367-71. doi: 10.5507/bp.2011.054.

http://www.ncbi.nlm.nih.gov/pubmed/22336650