Detection of deep venous thrombosis by scanning of 99mtechnetium-labelled red-cell venous pool.

A comparative study of 32 patients with suspected deep venous thrombosis was carried out using blood-pool radionuclide scanning and conventional x-ray phlebography. Results of the two methods showed close agreement, the sensitivity (positive correlation) of the scan being 100% and its specificity 89%. We conclude that a patient''s red cells labelled with 99mtechnetium (99mTc) provide an excellent medium for this type of scanning. The technique has particular advantages in visualising the whole venous system, giving a persisting image, and obviating the need to inject into a vein of the affected limb. In view of the inherent disadvantages of contrast phlebography, 99mTc-red-cell scanning is clearly an acceptable alternative.     

Diagnosis of Deep Vein Thrombosis with 99mTc-streptokinase: A Clinical Comparison with Phlebography

Nineteen patients with signs of deep vein thrombosis in the legs were investigated with a new technique using ^{9 9m}Tc-streptokinase. This compound is probably superior to iodine-labelled fibrinogen in detecting established thrombi. The ratio between the activity in the leg with suspected thrombosis and the other leg was calculated. The results were compared with those obtained with phlebography. A pathologically high activity ratio was found in 11 out of 13 patients in whom phlebography showed a thrombus, while the ratio was normal in the remaining six patients who showed no thrombus on phlebography. No negative correlation was found between the activity ratio and the titrated initial dose of streptokinase. The activity ratio as well as diagnosing the presence of a thrombus may also provide a guide for therapy.     

Diagnosis of deep vein thrombosis using autologous indium-III-labelled platelets.

Forty-eight patients who had undergone surgical reduction of a fractured neck of femur or in whom deep vein thrombosis was suspected clinically were studied by ascending phlebography and imaging after injection of autologous indium-111-labelled platelets to assess the accuracy and value of the radioisotopic technique in diagnosing deep vein thrombosis. Imaging was performed with a wide-field gammacamera linked with data display facilities. Phlebography showed thrombi in 26 out of 54 limbs examined and a thrombus in the inferior vena cava of one patient; imaging the labelled platelets showed the thrombi in 24 of the 26 limbs and the thrombus in the inferior vena cava. The accumulation of indium-111 at sites corresponding to those at which venous thrombi have been shown phlebographically indicates that this radioisotopic technique is a useful addition to methods already available for the detection of deep vein thrombosis.     

Low-molecular-weight heparin and prevention of postoperative deep vein thrombosis.

The efficacy of low-molecular-weight heparin as a prophylactic agent was assessed in 150 consecutive patients over the age of 40 undergoing major abdominal surgery. Fifty of these patients received 1250 activated partial thromboplastin time (APTT) units of low-molecular-weight heparin every 12 hours: three developed isotopic deep vein thrombosis, which was confirmed by phlebography in two cases. The other 100 patients received a single injection of 1850 APTT units of low-molecular-weight heparin. Three of them developed isotopic deep vein thrombosis; phlebography failed to confirm the presence of thrombi in each case. None of the 150 patients studied died from fatal or contributory pulmonary emboli. Low-molecular-weight heparin was not associated with any increase in preoperative or postoperative bleeding. The effect of equal amounts of postoperative bleeding. The effect of equal amounts of low-molecular-weight heparin and unfractionated heparin on the coagulation mechanism during surgery was investigated in another 30 patients. The clotting assays and results of in-vivo platelet function tests indicated that both preparations produced similar effect. Intragroup comparisons, however, showed significant differences in the anti-factor Xa activity, lipoprotein lipase release, and plasma prekallikrein concentrations. A single injection of low-molecular-weight heparin daily is a convenient way of preventing deep vein thrombosis in high-risk patients undergoing major abdominal surgery.     

Diagnosis of Established Deep Vein Thrombosis with the 125I Fibrinogen Uptake Test

One hundred and two patients with clinical signs indicating a possible diagnosis of deep vein thrombosis were studied with the fibrinogen uptake test and phlebography to assess the reliability of the test as a means of diagnosing established venous thrombosis. The test gave a correct diagnosis in 78% of the 85 legs shown to contain thrombus by phlebography and only 19 (10%) false-negative results in the 195 legs examined. The duration of the symptoms, the administration of anticoagulants, and mild leg swelling did not affect the accuracy of the test. Very old thrombus, phlebographically more than 11 days old, was associated with an increased false-negative rate.The fibrinogen uptake test is accurate enough to make it a valuable method of clinical investigation.     

Prevention of deep vein thrombosis after hip replacement: randomised comparison between unfractionated heparin and low molecular weight heparin.

OBJECTIVE--To evaluate the efficacy and safety of two subcutaneous prophylactic regimens for postoperative deep vein thrombosis after total hip replacement. DESIGN--Prospective open randomised multicentre trial. SETTING--28 European departments of orthopaedic surgery. INTERVENTION--All patients had bilateral phlebography 10 days after surgery. 31 patients receiving low molecular weight heparin and 29 receiving unfractionated heparin were excluded from the efficacy analysis for various reasons. PATIENTS--349 patients undergoing total hip replacement between September 1988 and May 1989. 174 patients received subcutaneously a low molecular weight heparin (Fraxiparine) with anti-factor Xa activity of 41 IU/kg/day for three days, then 62 IU/kg/day from day 4 to day 10. 175 patients received subcutaneous unfractionated heparin at intervals of eight hours; doses were adjusted to maintain the activated thromboplastin time at two to five seconds above control values. MAIN OUTCOME MEASURE--Total incidence of deep vein thrombosis and incidence of proximal deep vein thrombosis on bilateral phlebography. RESULTS--The total incidence of deep vein thrombosis was 16% in patients receiving unfractionated heparin and 12.6% in patients receiving low molecular weight heparin (p = 0.45), and the incidence of thrombosis of the proximal veins was 13.1% and 2.9% respectively (p less than 0.001). Four patients receiving unfractionated heparin and one receiving low molecular weight heparin developed pulmonary embolism. The incidence of bleeding complications was low and comparable in the two groups. CONCLUSION--Low molecular weight heparin is at least as effective as unfractionated heparin in preventing deep vein thrombosis and is more effective at preventing thrombosis of the proximal veins in patients undergoing hip replacement. Low molecular weight heparin is not more likely to cause bleeding complications and is simpler to give than unfractionated heparin.     

Treatment of deep vein thrombosis with streptokinase.

From September 1962 to May 1972 145 patients with acute or subacute deep vein thrombosis confirmed by phlebography were treated with streptokinase. During the same period 42 patients considered unfit for thrombolytic therapy were treated with herapin and oral anticoagulants. The results, assessed by repeat phlebography, in 93 of the patients treated with streptokinase were compared with those in 42 patients treated with heparin. The age, sex, and severity of occlusion were roughly similar in both groups. Streptokinase treatment was successful in 42 per cent, partially successful in 25 per cent, and unsuccessful in 32 per cent of the 93 patients compared with none, 10 per cent, and 88 percent respectively in the 42 patients treated with heparin. Streptokinase was more effective when the thrombus was in proximal rather than calf veins. Thrombi of more than six days old were readily lysed. Plasma fibrinogen levels were below 0-8 g/1 (80 mg/100 ml) in nearly all patients successfully treated. The incidence of pulmonary embolism was no greater with streptokinase than with heparin treatment. Only prolonged follow-up would show whether thrombolytic treatment would be effective in preventing late complications of deep vein thrombosis such as chronic venous insufficiency.     

Roentgeno-endovascular surgery of hypofunctional ovaries in varicosities of the ovarian veins]

Three degrees of ovarian varicocele in sterile women or women with menstrual disturbance were described on the basis of analysis of 62 superselective ovariophlebograms. A nonsurgical pathogenetic method for correction of ovarian hypofunction in disturbed circulation in the venous region of the pelvic organs was developed by cutting off the ovarian vein from the pathological renocaval vascular shunt with the help of roentgenovascular intervention. It is based upon transcatheter occlusion of the left ovarian vein and directly follows diagnostic phlebography. Roentgenoendovascular occlusion of the left ovarian vein was performed in 41 patients Ivanissevich's operation--in 8 patients. In 4-18 months after intervention, improved results of a clinical picture and functional diagnostic tests were observed in 46 patients. Of 19 women with passable uterine tubes 14 got pregnant.     

Prevention of Recurrent Pulmonary Embolism

Fifty patients have been studied by bilateral phlebography following their first, or sometimes recurrent, pulmonary embolus. Nineteen were found to have fresh loose peripheral thrombus, and in eight of them the thrombus looked big enough to cause a major pulmonary artery obstruction and death. These 19 patients were treated by vein ligation in addition to anticoagulants.The incidence of recurrent embolism in the trial group is significantly lower than that found in a retrospective study of 50 patients treated with anticoagulants only. It is suggested that anticoagulants will not prevent all recurrent pulmonary emboli, and that phlebography, and if necessary surgery, should be part of the routine investigation and treatment of all patients after their first pulmonary embolus.     

New Radioisotope Test for Detection of Deep Venous Thrombosis in the Legs

A radiopharmsceutical product, labelled macroaggregates of albumin (M.A.A.), which is in use as a lung scintiscanning agent has been noted to have an affinity for venous thrombi. With this material and an inexpensive portable scintillation detector we have attempted to diagnose and localize thrombi in leg veins. The procedure is performed at the bedside and the result is available in 30 minutes. Thirty-one patients with clinical evidence suggestive of deep venous thrombosis in the legs were studied by the radioisotope method and by phlebography. There was agreement in 18 of 21 legs shown to contain thrombus on phlebography and in 9 of 10 legs shown to be free of thrombosis on phlebography. There was, however, lesser agreement on the site of thrombosis between the two methods. The ease of performing the test combined with the rapidity of obtaining results and accuracy in diagnosis suggests that the test has a clinical application.     

Treatment of Deep Vein Thrombosis. A Trial of Heparin,Streptokinase, and Arvin

Thirty patients with deep vein thrombosis of the legs of less than four days'' duration were allocated at random to treatment with heparin, streptokinase, or Arvin under laboratory control. When the fate of the thrombi was assessed by objective techniques—phlebography and the ¹²⁵I-labelled fibrinogen test—the incidence of complete thrombolysis was greatest in the streptokinase group. Complications arose during treatment in each group but were least with Arvin. The natural history of the disease favours clinical but not always anatomical recovery.     

Incidence of early post-operative iliofemoral thrombosis.

The doppler ultrasound probe was used to study 138 patients after major surgery to assess the incidence of iliofemoral thrombosis in the early postoperative period. The patients were simultaneously studied with the 125-I-fibrinogen uptake test. The accuracy of the ultrasonic technique was assessed concurrently by comparing its results with those of ascending phlebography in a separate group of patients. The ultrasound probe detected thrombus proximal to the calf but was inaccurate in locating its exact site. Of the 138 patients studied postoperatively 28 developed calf vein thrombosis detected istopically, but there was no evidence of iliofemoral thrombosis in any patient. Thus, spontaneous iliofemoral thrombosis in the early postoperative period is rare.     

Role of radiologic diagnosis in the evaluation of morphologic and functional changes in muscular veins of the leg in the pathogenesis of varicose disease]

A total of 100 patients with varicosis of lower limb veins were investigated with the help of distal ascending phlebography in horizontal, vertical and tilted positions. Considerable differences in x-ray images of musculi gastrocnemius and soleus (MGS) were noted. Four main types of MGS (conic, spindle-form, U-form, and balloon-like) were singled out. Correlation between muscular vein sizes and stages of varicosis was revealed. An important role of the pathology of muscular veins in dysfunction of the leg pump as one of the factors of pathogenesis of lower limb varicosis was confirmed.     

Umbilical vein variations: review of the literature and a case report of a persistent right umbilical vein

A case of a ligamentum teres formed from an obliterated right umbilical vein is described. It passed to the right branch of the portal vein. The quadrate and left lobes of the liver were not separated by the usual fissure. Very few cases of anomalous umbilical veins or persistent right umbilical veins have been recorded. Of these, several have been recorded only in the umbilical cord, while in others the persistent right umbilical vein has been found intra-abdominally, in an extrahepatic position, and passing directly to the right atrium or to the inferior vena cava. Its presence is generally associated with severe congenital abnormalities, in contrast with the present case. In view of the high incidence of congenital defects associated with aberrant or accessory umbilical veins, when these are detected either in the umbilical cord or in the abdomen by umbilical phlebography, it is suggested that the patient should be carefully investigated for other congenital abnormalities.     

Clinico-roentgenologic diagnosis of chronic venous insufficiency of the ovaries

The paper is devoted to clinico-roentgenological correlations of venous reno-gonadal hemodynamics in 168 women of reproductive age (151 women with infertility, habitual abortion, disordered menstrual function and 17 patients without disorders of the reproductive tract). Clinico-laboratory investigation was followed by visceral and parietal phlebography for the detection of a pathological venous reflux into the ovarian pampiniform plexus. A retrograde blood flow along the internal ovarian vein with the development of venostasis and secondary pelvic varicocele was diagnosed in 67 women with disturbed reproductive function. In 17 women without disorders of reproductive function a reno-gonadal venous reflux was undetectable. Clinico-roentgenological semiotics of chronic venous ovarian insufficiency was analyzed. Infertility was shown to be the main clinical manifestation of ovarian varicocele.     

Complications of ascending phlebography of the leg.

Forty patients were studied prospectively for complications of ascending phlebography. The commonest immediate complication was pain at the site of injection and the commonest delayed complication pain in the foot or calf. Out of 30 patients with pain in the foot and calf, 15 had venous thrombosis. Review of 200 case notes disclosed only one recorded complication--namely, necrosis of the dorsal skin of the foot. Complications of the procedure reported by referring clinicians over 10 years comprised four cases of necrosis of the dorsum of the foot and two of gangrene of the foot, in one of which the gangrene spread to the leg. Major complications of ascending phlebography are rare, though when they occur may cause serious morbidity. If a scrupulous technique is used contrast phlebography remains the most accurate method of diagnosing venous disease of the leg.     

Failure of low-dose heparin to prevent significant thromboembolic complications in high-risk surgical patients: interim report of prospective trial. Groote Schuur Hospital Thromboembolus Study Group.

The efficacy of low-dose subcutaneous heparin (5000 IU eight-hourly) is being studied in a single-centre, prospective randomised trial of patients aged over 40 submitted to major elective intra-abdominal surgery. The trial end-points are the objectively defined incidence and extent of deep vein thrombosis (as seen on uptake of 125I-labelled fibrinogen, Doppler ultrasonography, and bilateral ascending phlebography) and non-fatal pulmonary embolus (as measured by preoperative spirometry and preoperative and postoperative chest radiography and perfusion lung scanning performed on a routine, unselected basis). An interim analysis of the first 200 patients indicates that low-dose heparin significantly reduces the incidence of calf-vein thrombosis but does not reduce the incidence of proximal segment thrombosis or non-fatal pulmonary embolism. Thus the routine use of low-dose heparin prophylaxis in all major surgical procedures in patients aged over 40 may not be advisable.     

Subcutaneous calcium heparin versus intravenous sodium heparin in treatment of established acute deep vein thrombosis of the legs: a multicentre prospective randomised trial.

One hundred patients with phlebographically proved acute deep vein thrombosis of the legs were prospectively randomised into two treatment groups to compare the safety and efficacy of subcutaneous calcium heparin versus intravenous sodium heparin administered by constant infusion pump. The dose of heparin was determined by daily measurement of the kaolin cephalin clotting time. Treatment was maintained for up to 14 days, after which phlebography was repeated. Of 49 patients who received subcutaneous calcium heparin, two showed an increase in thrombus size, while eight showed complete lysis. In the 47 patients who received intravenous sodium heparin thrombus increased in size in 13 while only one showed evidence of complete lysis. These differences were significant. There were no significant differences between the two groups in the incidence of serious complications, although almost half of those receiving intravenous heparin had some minor problem with the constant infusion pump and just over half of those receiving subcutaneous heparin had some bruising at the injection site. This study showed that subcutaneous calcium heparin was more effective in helping lyse existing thrombus and preventing its propagation than intravenous sodium heparin.     

Detection and Management of Deep Vein Thrombosis

The accuracy of diagnosis of deep venous thrombosis is significantly improved by combining clinical evaluation with other adjunctive methods, especially fibrinogen uptake tests, technetium scans, Doppler techniques and phlebography. Using these studies, early treatment with intravenous administration of heparin can be begun and in selected cases with long-term risks, warfarin is often useful. These same drugs, in different dosage schedules, may also be helpful as prophylaxis. With these methods of treatment, thrombectomy and caval interruption are required less often. If interruption of inferior vena cava flow becomes necessary, several new methods utilizing intracaval filters are proving to be very useful.     

Adrenal aldosterone-producing adenoma: use of colonic potential in diagnosis and subtraction scanning technique for localisation.

Primary hyperaldosteronism is a potentially curable cause of hypertension, and much interest has been shown in methods of diagnosing the associated hypokalaemic hypertension and localising the adrenal adenoma. In two patients the diagnosis of primary aldosteronism was confirmed by colonic potential measurement and the adenoma localised by a new subtraction technique for early adrenal imaging applied to the use of 131I-19-iodocholesterol. Both patients underwent adrenalectomy and in each case an adenoma was removed. Blood pressure and electrolyte levels returned to normal after operation. In one patient bilateral adrenal phlebography had failed to show the tumour, and sampling of aldosterone concentrations in the adrenal veins had been unsatisfactory.