Deep Venous Thrombosis and Pulmonary Thromboembolism in a Physically Nonprepared Trekker in the Himalayas: An Autopsy Report

Deep Venous Thrombosis (DVT) and Subsequent Pulmonary Thromboembolism (PTE) in high altitude climbers is a well-known concept. The acclimatization process at high altitude is itself a thrombogenic event. Accordingly, when a physically nonprepared individual with preexisting thrombogenic risk factors attempts trekking at high altitude, they may end up with fatal thromboembolic events. Here, we report a case of a low-lander with multiple thrombogenic risk factors who developed DVT and PTE when he went for a trekking trip in the Himalayas. The risk factors, autopsy findings, and possible mechanism of developing fatal pulmonary embolism, in this case, are discussed here.

Immobility due to COVID-19 confinement, use of contraceptives and presence of the G20210A mutation. Validity of the Virchow triad for the presentation of Deep Venous Thrombosis and Pulmonary Thromboembolism.

Venous thromboembolic disease is a complex and multifactorial pathology, the result of the interaction of both genetic and environmental factors. The Virchow triad, first described in 1859, is still valid to explain the pathogenesis of thrombosis, where three main factors are reflected: a) hypercoagulable state; b) impaired blood flow; c) endothelial injury. The outbreak of a new COVID-19 pandemic has led to drastic confinement measures, with the consequent syndrome of immobility, as occurred in Spain between the months of March to June 2020. Pregnancy and hormonal contraception have proven to be an environmental factor predisposing to venous thrombosis. The presence of genetic factors, such as the mutation of the prothrombin gene G20210A, has been shown to be a risk factor for the presentation of venous thrombosis. We present the case of a 23-year-old non-smoking woman, a heterozygous carrier of a prothrombin gene mutation G20210A (hypercoagulability), who after confinement due to COVID-19 (impaired blood flow due to immobility) and use of hormonal patch contraceptives (endothelial abnormality), triggered deep vein thrombosis (DVT) / pulmonary thromboembolism (PE) that required hospital admission; and who, after rapid withdrawal of anticoagulant treatment, presented a second and a third episode of DVT. We highlight the usefulness of evaluating risk factors in G20210A heterozygous patients and the proper management of anticoagulation to avoid recurrences in patients susceptible to DVT / PE.

Acute Pulmonary Embolism Post COVID-19 Pneumonia – A Case Report

COVID-19 has been associated with multiple venous thromboembolism events such as pulmonary embolism and deep vein thrombosis. Here we report a 64-year male with COVID-19 pneumonia who developed pulmonary thromboembolism following the COVID illness. This patient developed VTE complication in spite of receiving anti-coagulation therapy during admission. This case brings out the need for evidence-based post-discharge VTE prophylaxis approach and guidelines in patients who recover from COVID-19.

Immobility due to COVID-19 confinement, use of contraceptives and presence of the G20210A mutation. Validity of the Virchow triad for the presentation of Deep Venous Thrombosis and Pulmonary Thromboembolism.

Venous thromboembolic disease is a complex and multifactorial pathology, the result of the interaction of both genetic and environmental factors. The Virchow triad, first described in 1859, is still valid to explain the pathogenesis of thrombosis, where three main factors are reflected: a) hypercoagulable state; b) impaired blood flow; c) endothelial injury. The outbreak of a new COVID-19 pandemic has led to drastic confinement measures, with the consequent syndrome of immobility, as occurred in Spain between the months of March to June 2020. Pregnancy and hormonal contraception have proven to be an environmental factor predisposing to venous thrombosis. The presence of genetic factors, such as the mutation of the prothrombin gene G20210A, has been shown to be a risk factor for the presentation of venous thrombosis. We present the case of a 23-year-old non-smoking woman, a heterozygous carrier of a prothrombin gene mutation G20210A (hypercoagulability), who after confinement due to COVID-19 (impaired blood flow due to immobility) and use of hormonal patch contraceptives (endothelial abnormality), triggered deep vein thrombosis (DVT) / pulmonary thromboembolism (PE) that required hospital admission; and who, after rapid withdrawal of anticoagulant treatment, presented a second and a third episode of DVT. We highlight the usefulness of evaluating risk factors in G20210A heterozygous patients and the proper management of anticoagulation to avoid recurrences in patients susceptible to DVT / PE.

Complications Associated With Totally Implanted Venous Access Devices in the Arm Versus the Chest: A Short-Term Retrospective Study

Purpose: To retrospectively compare complications for totally implanted venous access devices (TIVADs or ports) in the arm vs. the chest. One participating institution implanted all TIVADs in the arm, whereas the other institution implanted them in the chest. Methods: Subjects were consecutive patients > 18 years with a device inserted between July 2017 and January 2019 at either Hospital A, where all devices were implanted in the arm, or at Hospital B, where all devices were implanted in the chest. Complications (rates/1,000 catheter-days and frequencies) were compared between the arm and chest locations. Results: 201 arm devices (71% female, mean age 59.4 years) and 203 chest devices (66% female, mean age 61.5 years) were assessed. Overall complication rates did not differ between the arm and chest [arm: 30 complications per 56,938 catheter-days (0.530/1,000 catheter-days) vs. chest: 47 complications per 63,324 catheter-days (0.742/1,000 catheter-days), p-value 0.173]. Periprocedural complications and mechanical malfunction also did not differ. Although prophylactic antibiotic use was higher in the chest (79.3% vs. 1.50%, p-value < 0.0001), infection rates did not differ. Arm venous thrombosis was significantly higher in the arm cohort (0.205 vs. 0.017/1,000 catheter-days, p-value 0.003) and pulmonary thromboembolism in the chest cohort (0.269 vs 0.056/1,000 catheter-days, p-value 0.002). Conclusions: While arm venous thrombosis was higher in the arm and pulmonary thromboembolism in the chest cohort, other complications were similar. Antibiotic use was more frequent in the chest cohort, while infection rates remained similar in both cohorts.

Investigation of the Need for Computed Tomography Pulmonary Angiography in the Decision to Discontinue Treatment for Pulmonary Thromboembolism

Purpose: Acute pulmonary thromboembolism (PTE) is an important cause of morbidity and mortality that can reduce quality of life due to long-term complications during and after treatment discontinuation. The aim of this study was to evaluate patients for these complications before discontinuing treatment and determine the necessity of computed tomography pulmonary angiography (CTPA) imaging.Methods: This retrospective study included 116 patients over the age of 18 who received anticoagulant treatment for at least 3 months and presented for treatment discontinuation to the Atatürk University Research Hospital Chest Diseases Outpatient Clinic between January 2015 and September 2019. Results: CTPA performed at treatment discontinuation showed complete thrombus resolution with treatment in 73 patients (62.9%). High pulmonary artery obstruction index (PAOI) at diagnosis was statistically associated with findings of residual or chronic thrombus on CTPA at treatment discontinuation (p=0.001). In the differentiation of patients with residual/chronic thrombus and those with thrombus resolution, D-dimer at a cut-off value of 474 µg/L had 60% sensitivity and 70% specificity. At a cut-off value of 35.5 mmHg, mean pulmonary artery pressure on echocardiography had sensitivity and specificity of 72% and 77%, respectively. At a cut-off of 23.75, PAOI had sensitivity and specificity of 93% and 69%, respectively.Discussion: In addition to physical examination findings, D-dimer and echocardiography were guiding parameters in the evaluation of treatment discontinuation and thrombus resolution in patients presenting to the outpatient clinic for discontinuation of treatment for acute PTE. PAOI at diagnosis may be another important guiding parameter in addition to these examinations.