D-dimer plasma level: a reliable marker for venous thromboembolism after elective craniotomy

Object The incidence of deep venous thrombosis (DVT) after craniotomy is reported to be as high as 50%. In outpatients, D-dimer levels of more than 0.5 mg/L indicate venous thromboembolism (VTE, which subsumes DVT and pulmonary embolism [PE]) with a sensitivity of 99.4% and a specificity of 38.2%. However, D-dimer levels are believed to be unreliable in postoperative patients. The authors undertook the present study to test the hypothesis that D-dimer levels would be systematically raised in a postoperative population and to define a feasible threshold for identification of VTE. Methods Doppler ultrasonography of the lower extremity was performed pre- and postoperatively to evaluate for DVT in 101 patients who underwent elective craniotomy. D-dimer levels were assessed preoperatively and on the 3rd, 7th, and 10th days after surgery. Statistical analysis was carried out to define a feasible threshold for D-dimer levels. Results D-dimer plasma levels were found to be systematically raised postoperatively, and they differed between patients with and without VTE in a highly significant way. On the 3rd day after surgery, D-dimer levels of more than 2 mg/L indicated VTE with a sensitivity of 95.3% and a specificity of 74.1%, allowing for the definition of a feasible threshold. D-dimer levels of more than 4 mg/L were observed in all patients who had PE during the postoperative period (n = 9). Ventilation time and duration of surgery were identified as highly significant risk factors for the development of VTE. Conclusions Using a threshold of 2 mg/L, D-dimer levels will indicate VTE with a high degree of sensitivity and specificity in patients who have undergone craniotomy. Pulmonary embolism seems to be indicated by even higher D-dimer levels. Given that the development of D-dimer plasma levels in the postoperative period follows a principle that can be predicted and that deviations from it indicate VTE, this principle might be applicable to other types of surgery.

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d-Dimer as a Screening Marker for Venous Thromboembolism After Surgery Among Patients Younger Than 50 With Lower Limb Fractures

Clinical and Applied Thrombosis/Hemostasis ◽

10.1177/1076029615588784 ◽

2016 ◽

Vol 23 (1) ◽

pp. 78-83 ◽

Cited By ~ 7

Author(s):

Yong Yang ◽

Pengfei Zan ◽

Jinpeng Gong ◽

Ming Cai

Keyword(s):

Venous Thromboembolism ◽

Lower Limb ◽

Significant Risk ◽

Lower Limbs ◽

Cutoff Value ◽

Vein Thrombosis ◽

Lower Limb Fractures ◽

Duration Of Surgery ◽

Limb Fractures ◽

D Dimer

Objective: For the present study, the authors hypothesized that the d-dimer levels would be systematically raised in a postoperative population of patients younger than 50 with lower limb fractures and to define a feasible cutoff value for identification of venous thromboembolism (VTE). Methods: Doppler ultrasonography of lower limbs was performed pre- and postoperatively to evaluate for deep vein thrombosis in 150 patients who underwent open reduction and internal fixation (ORIF). Plasma d-dimer levels were assessed 2 days before surgery and on the 3rd, 7th, and 10th days after surgery. Statistical analysis was carried out to define a feasible threshold for the d-dimer levels. Results: Plasma d-dimer levels were found to be systematically raised postoperatively, and they differed between patients with and without VTE significantly. On the third day after surgery, d-dimer levels of more than 3 mg/L indicated VTE with a sensitivity of 88.37% and a specificity of 96.96%, allowing for the definition of a feasible cutoff value. Duration of surgery, duration of tourniquet, ventilation time, and time of postoperative immobility of lower limbs were identified as highly significant risk factors for the development of VTE. Conclusion: Using a threshold of 3 mg/L, the d-dimer levels will screen out VTE with a high degree of sensitivity and specificity in younger patients who have undergone ORIF for lower limb fractures.

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Venous thromboembolism: deep venous thrombosis and pulmonary embolism in a neurosurgical population

Journal of Neurosurgery ◽

10.3171/2010.8.jns10332 ◽

2011 ◽

Vol 114 (1) ◽

pp. 40-46 ◽

Cited By ~ 57

Author(s):

Ahmad Khaldi ◽

Naseem Helo ◽

Michael J. Schneck ◽

Thomas C. Origitano

Keyword(s):

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Lower Extremity ◽

Linear Correlation ◽

Pharmacological Prophylaxis ◽

Neurosurgical Procedure ◽

Dvt Prophylaxis ◽

Subcutaneous Heparin ◽

Neurosurgical Patients ◽

Duration Of Surgery

Object Venous thromboembolism (VTE), a combination of deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major cause of morbidity and death in neurosurgical patients. This study evaluates 1) the risk of developing lower-extremity DVT following a neurosurgical procedure; 2) the timing of initiation of pharmacological DVT prophylaxis upon the occurrence of VTE; and 3) the relationship between DVT and PE as related to VTE prophylaxis in neurosurgical patients. Methods The records of all neurosurgical patients between January 2006 and December 2008 (2638 total) were reviewed for clinical documentation of VTE. As part of a quality improvement initiative, a subgroup of 1638 patients was studied during the implementation of pharmacological prophylaxis. A high-risk group of 555 neurosurgical patients in the intensive care unit underwent surveillance venous lower-extremity duplex ultrasonography studies twice weekly. All patients throughout the review received mechanical DVT prophylaxis. Pharmacological DVT prophylaxis, consisting of 5000 U of subcutaneous heparin twice daily (initially started within 48 hours of a neurosurgical procedure and subsequently within 24 hours of a procedure) was implemented in combination with mechanical prophylaxis. The DVT and PE rates were calculated for each group. Results In the surveillance group (555 patients), 84% of the DVTs occurred within 1 week and 92% within 2 weeks of a neurosurgical procedure. There was a linear correlation between the duration of surgery and DVT development. The use of subcutaneous heparin reduced the rate of DVT from 16% to 9% when medication was given at either 24 or 48 hours postoperatively, without any increase in hemorrhagic complications. In the overall group (2638 patients), there were 94 patients who exhibited clinical signs of a possible PE and therefore underwent spiral CT; 22 of these patients (0.8%) had radiological confirmation of PE. There was no correlation between the use of pharmacological prophylaxis at either time point and the occurrence of PE, despite a 43% reduction in the lower-extremity DVT rate with pharmacological intervention. Conclusions The majority of DVTs occurred within the first week after a neurosurgical procedure. There was a linear correlation between the duration of surgery and DVT occurrence. Use of early subcutaneous heparin (at either 24 or 48 hours) was associated with a 43% reduction of developing a lower-extremity DVT, without an increase in surgical site hemorrhage. There was no association of pharmacological prophylaxis with overall PE occurrence.

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Venous Thromboembolism

10.2310/fm.1102 ◽

2020 ◽

Author(s):

Samuel Z. Goldhaber

Keyword(s):

Risk Factors ◽

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Venous Thrombosis ◽

Antithrombotic Agents ◽

Vein Thrombosis ◽

Recurrent Venous Thrombosis ◽

Deep Vein ◽

D Dimer ◽

In Pregnancy

Venous thromboembolism, which involves venous thrombosis and pulmonary embolism, is a leading cause of morbidity and mortality in hospitalized patients and is being seen with increasing frequency in outpatients. This chapter discusses the risk factors, etiology, classification, pathophysiology, natural history, prognosis, diagnosis (including venous thrombosis, recurrent venous thrombosis, and pulmonary embolism), prophylaxis, and treatment of venous thromboembolism (including the pharmacology of antithrombotic agents), as well as venous thromboembolism in pregnancy and miscellaneous thromboembolic disorders (including thrombosis of unusual sites). This review contains 8 figures, 16 tables, and 79 references. Keywords: Venous thromboembolism, pulmonary embolism, deep vein thrombosis, embolectomy, thrombolysis, hypercoagulability, duplex ultrasonography, D-dimer, anticoagulation

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Advances in the Diagnosis of Venous Thromboembolism: A Literature Review

Diagnostics ◽

10.3390/diagnostics10060365 ◽

2020 ◽

Vol 10 (6) ◽

pp. 365 ◽

Cited By ~ 3

Author(s):

Harish Patel ◽

Haozhe Sun ◽

Ali N. Hussain ◽

Trupti Vakde

Keyword(s):

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Valsalva Maneuver ◽

Imaging Modality ◽

Diagnostic Algorithm ◽

Pulmonary Angiography ◽

Vein Thrombosis ◽

Compression Ultrasound ◽

Test Probability ◽

D Dimer

The incidence of venous thromboembolism (VTE), including lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) is increasing. The increase in suspicion for VTE has lowered the threshold for performing imaging studies to confirm diagnosis of VTE. However, only 20% of suspected cases have a confirmed diagnosis of VTE. Development of pulmonary embolism rule-out criteria (PERC) and update in pre-test probability have changed the paradigm of ruling-out patient with low index of suspicion. The D-dimer test in conjunction to the pre-test probability has been utilized in VTE diagnosis. The age appropriate D-dimer cutoff and inclusion of YEARS algorithm (signs of the DVT, hemoptysis and whether PE is the likely diagnosis) for the D-dimer cutoff have been recent updates in the evaluation of suspected PE. Multi-detector computed tomography pulmonary angiography (CTPA) and compression ultrasound (CUS) are the preferred imaging modality to diagnose PE and DVT respectively. The VTE diagnostic algorithm do differ in pregnant individuals. The prerequisite of avoiding excessive radiation has recruited planar ventilation-perfusion (V/Q) scan as preferred in pregnant patients to evaluate for PE. The modification of CUS protocol with addition of the Valsalva maneuver should be performed while evaluating DVT in pregnant individual.

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Reduced risk of venous thromboembolism with the use of intermittent pneumatic compression after craniotomy: a randomized controlled prospective study

Journal of Neurosurgery ◽

10.3171/2017.9.jns17533 ◽

2019 ◽

Vol 130 (2) ◽

pp. 622-628 ◽

Cited By ~ 3

Author(s):

Julian Prell ◽

Grit Schenk ◽

Bettina-Maria Taute ◽

Christian Scheller ◽

Christian Marquart ◽

...

Keyword(s):

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Prospective Study ◽

Controlled Trial ◽

Intermittent Pneumatic Compression ◽

Control Group ◽

Compression Stockings ◽

Clinical Trial Registration ◽

Randomized Controlled ◽

Duration Of Surgery

OBJECTIVEThe term “venous thromboembolism” (VTE) subsumes deep venous thrombosis (DVT) and pulmonary embolism. The incidence of DVT after craniotomy was reported to be as high as 50%. Even clinically silent DVT may lead to potentially fatal pulmonary embolism. The risk of VTE is correlated with duration of surgery, and it appears likely that it develops during surgery. The present study aimed to evaluate intraoperative use of intermittent pneumatic compression (IPC) of the lower extremity for prevention of VTE in patients undergoing craniotomy.METHODSA total of 108 patients undergoing elective craniotomy for intracranial pathology were included in a single-center controlled randomized prospective study. In the control group, conventional compression stockings were worn during surgery. In the treatment group, IPC of the calves was used in addition. The presence of DVT was evaluated by Doppler sonography pre- and postoperatively.RESULTSIntraoperative use of IPC led to a significant reduction of VTE (p = 0.029). In logistic regression analysis, the risk of VTE was approximately quartered by the use of IPC. Duration of surgery was confirmed to be correlated with VTE incidence (p < 0.01); every hour of surgery increased the risk by a factor of 1.56.CONCLUSIONSIntraoperative use of IPC significantly lowers the incidence of potentially fatal VTE in patients undergoing craniotomy. The method is easy to use and carries no additional risks.■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: randomized controlled trial; evidence: class I.Clinical trial registration no.: DRKS00011783 (https://www.drks.de)

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Performance of a diagnostic algorithm based on a prediction rule, D-dimer and CT-scan for pulmonary embolism in patients with previous venous thromboembolism

Thrombosis and Haemostasis ◽

10.1160/th14-06-0488 ◽

2015 ◽

Vol 113 (02) ◽

pp. 406-413 ◽

Cited By ~ 15

Author(s):

Paul L. den Exter ◽

Inge C. M. Mos ◽

Menno V. Huisman ◽

Frederikus A. Klok ◽

Maria José Fabiá Valls ◽

...

Keyword(s):

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Random Effect ◽

Prediction Rule ◽

Diagnostic Algorithm ◽

Clinical Prediction Rule ◽

Incidence Rates ◽

Specific Patient ◽

History Of ◽

D Dimer

SummaryDiagnostic management of suspected pulmonary embolism (PE) in patients with a history of venous thromboembolism (VTE) is complicateddue to persistent abnormal D-dimer levels, residual embolic obstruction and higher clinical prediction rule (CPR) scores. We aimed to evaluate the safety and efficiency of the standard diagnostic algorithm consisting of a CPR, D-dimer test and computed tomography pulmonary angiography (CTPA) in this specific patient category. We performed a systematic literature search for prospective studies evaluating a diagnostic algorithm in consecutive patients with clinically suspected PE and a history of VTE. The VTE incidence rates during three-month follow-up and the number of indicated CTPAs were pooled using random effect models. Four studies concerning 1,286 patients were included with a pooled baseline PE prevalence of 36 % (95 % confidence interval [CI] 30–42). In only 217 patients (15 %; 95 %CI 11–20) PE could be excluded without CTPA. The three-month VTE incidence rate was 0.8 % (95 %CI 0.06–2.4) in patients managed without CTPA, 1.6 % (95 %CI 0.3–4.0) in patients in whom PE was excluded by CTPA and 1.4 % (95 %CI 0.6–2.7) overall. In the pooled studies, PE was safely excluded in patients with a history of VTE based on a CPR followed by a D-dimer test and/or CTPA, although the efficiency of the algorithm is relatively low compared to patients without a history of VTE.

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Predictive Value of D-Dimer Levels for Venous Thromboembolism in Cancer Patients: Results from the Vienna Cancer and Thrombosis Study (CATS)

Blood ◽

10.1182/blood.v112.11.3824.3824 ◽

2008 ◽

Vol 112 (11) ◽

pp. 3824-3824

Author(s):

Cihan Ay ◽

Rainer Vormittag ◽

Daniela Dunkler ◽

Ralph Simanek ◽

Alexandru-Laurentiu Chiriac ◽

...

Keyword(s):

Venous Thromboembolism ◽

Cancer Patients ◽

Predictive Value ◽

Significant Risk ◽

Cumulative Probability ◽

Total Study Population ◽

Cox Regression Analysis ◽

Increased Risk ◽

Diagnosis Of Cancer ◽

D Dimer

Abstract Venous thromboembolism (VTE) is a frequent complication of cancer, which represents a major cause of morbidity and mortality in cancer patients. Laboratory parameters with a predictive value for VTE could help to assign a patient to a high or low risk group. D-Dimer is a global indicator of coagulation activation and fibrinolysis and is frequently elevated in cancer patients, even without thrombosis. The measurement of D-dimer levels is a widely applied test in the diagnostic work-up of patients with suspected VTE. Prospective observational studies have shown that D-dimer levels have a predictive value for the risk of recurrence in non-cancer patients after the discontinuation of oral anticoagulant treatment. Whether testing for D-Dimer at diagnosis of cancer would be useful for prediction of cancer-associated thrombosis, is not elucidated because up to now appropriately designed prospective studies have not yet been carried out. Therefore, we have assessed D-Dimer levels in cancer patients as risk predictor for VTE and provide a report from the ongoing prospective observational CATS, which was initiated in October 2003. Patients with newly diagnosed cancer or progression of disease that had neither chemotherapy within the last three months, nor radiotherapy nor surgery within the last two weeks were recruited and followed prospectively. Occurrence of VTE and information on the patients’ anti-cancer-treatment within the follow up period were recorded. Observation ended with occurrence of VTE, death or after 2 years. VTE has always been confirmed by imaging. D-Dimer levels were measured with a D-Dimer latex agglutination assay. Kaplan Meier and Cox regression analysis were applied for statistical calculation. Data on 821 patients with cancer (370 women/451 men, median age [IQR]: 62 [53–68] yrs) were available for analyses. Patients were followed for a median observation time of 454 days. Main tumour entities were malignancies of the breast (n=132), lung (n=119), upper (n=35) and lower gastrointestinal tract (n=106), pancreas (n=46), kidney (n=22) and prostate (n=101). Furthermore, 102 patients had high-grade glioma, 94 lymphomas, 17 multiple myeloma and 47 other tumour types. During the observation period VTE occurred in 62 patients (24 female/38 male, median age [IQR]: 60 [50–66] yrs). Elevated levels of D-Dimer (cut-off level 1.44 μg/ml, representing the 75th percentile of the total study population) [hazard ratio (HR): 2.4, 95% CI 1.4–4.0], surgery [HR: 2.3, 95% CI 1.0–5.3] and radiotherapy [HR: 2.3, 95% CI 1.2–4.4] were statistically significant risk factors for VTE in multivariate analysis including D-Dimer, age, sex, surgery, chemotherapy and radiotherapy. The cumulative probability of developing VTE after 6 months was 11.2 % in patients with D-Dimer levels above and 4.2 % in those below the 75th percentile (p=0.003). In conclusion, cancer patients with elevated D-Dimer levels have an approximately 3-fold increased risk for future occurrence of VTE. High levels of D-Dimer independently predict VTE in these patients and D-Dimer measurement at diagnosis of cancer would help identify patients at increased risk for VTE.

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Comparison of clinical probability-adjusted D-dimer and age-adjusted D-dimer interpretation to exclude venous thromboembolism

Thrombosis and Haemostasis ◽

10.1160/th17-03-0182 ◽

2017 ◽

Vol 117 (10) ◽

pp. 1937-1943 ◽

Cited By ~ 9

Author(s):

Jim Julian ◽

Lori-Ann Linkins ◽

Shannon Bates ◽

Clive Kearon ◽

Sarah Takach Lapner

Keyword(s):

Pulmonary Embolism ◽

Deep Vein Thrombosis ◽

Venous Thromboembolism ◽

Diagnostic Accuracy ◽

Blood Samples ◽

Vein Thrombosis ◽

Clinical Probability ◽

Deep Vein ◽

New Strategies ◽

D Dimer

SummaryTwo new strategies for interpreting D-dimer results have been proposed: i) using a progressively higher D-dimer threshold with increasing age (age-adjusted strategy) and ii) using a D-dimer threshold in patients with low clinical probability that is twice the threshold used in patients with moderate clinical probability (clinical probability-adjusted strategy). Our objective was to compare the diagnostic accuracy of age-adjusted and clinical probability-adjusted D-dimer interpretation in patients with a low or moderate clinical probability of venous thromboembolism (VTE). We performed a retrospective analysis of clinical data and blood samples from two prospective studies. We compared the negative predictive value (NPV) for VTE, and the proportion of patients with a negative D-dimer result, using two D-dimer interpretation strategies: the age-adjusted strategy, which uses a progressively higher D-dimer threshold with increasing age over 50 years (age in years × 10 µg/L FEU); and the clinical probability-adjusted strategy which uses a D-dimer threshold of 1000 µg/L FEU in patients with low clinical probability and 500 µg/L FEU in patients with moderate clinical probability. A total of 1649 outpatients with low or moderate clinical probability for a first suspected deep vein thrombosis or pulmonary embolism were included. The NPV of both the clinical probability-adjusted strategy (99.7%) and the age-adjusted strategy (99.6%) were similar. However, the proportion of patients with a negative result was greater with the clinical probability-adjusted strategy (56.1% vs, 50.9%; difference 5.2%; 95% CI 3.5% to 6.8%). These findings suggest that clinical probability-adjusted D-dimer interpretation is a better way of interpreting D-dimer results compared to age-adjusted interpretation.

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