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A review of patients with deep vein thrombosis diagnosed at University Hospital, Kuala Lumpur

Liam CK, Ng SC

Ann Acad Med Singap, 1990 Nov;19(6):837-40.
PMID: 2130750

In this retrospective study, 81 patients were diagnosed to have deep vein thrombosis (DVT) at the University Hospital, Kuala Lumpur over a ten year period from 1977 to 1986. Fifty-six patients had their DVT confirmed by venograms. The left side was affected in 79.5% of venographically proven cases of DVT of the lower limbs above the popliteal vein. The incidence of clinically apparent DVT following surgery was 0.21 per 1,000 operations. The incidence of pregnancy-related DVT was 0.039%. DVT was 3 times more frequent in the puerperium than in the antenatal period. The overall incidence of symptomatic pulmonary embolism was 13.6% of the cases of DVT.

Matched MeSH terms: Thrombosis/etiology*
An uncommon mediastinal cyst with a rare neurologic consequence

Sivalingam S, Qureshi AU, Chern LM, Latiff HA

Ann Thorac Surg, 2014 Apr;97(4):e93-5.
PMID: 24694456 DOI: 10.1016/j.athoracsur.2013.12.060

Enteric cysts are uncommon posterior mediastinal cysts, usually presenting with respiratory symptoms in infancy. We present a rare case of posterior mediastinal enteric cyst extending from below the diaphragm and perforating into the left atrium, causing a thromboembolic cerebral infarct in a 5-year-old boy.

Matched MeSH terms: Intracranial Thrombosis/etiology*
Arterial thrombosis and critical limb ischaemia in a case of nephrotic syndrome

Koh KH, Tan C, Tan S, Ngu L

Nephrology (Carlton), 2009 Sep;14(6):622.
PMID: 19712262 DOI: 10.1111/j.1440-1797.2008.01001.x
Matched MeSH terms: Thrombosis/etiology*
Autogenous forearm loop arteriovenous fistula creation

Tang WJ, Mat Saad AZ

J Vasc Access, 2018 Mar;19(2):191-194.
PMID: 29148006 DOI: 10.5301/jva.5000801

INTRODUCTION: Arteriovenous fistula is a lifeline for end-stage kidney disease patients on dialysis. The quality of the vein and artery to be used plays a crucial role in attaining a functioning, reliable and long-lasting arteriovenous fistula. The aim of the study is to present an alternative for haemodialysis access to preserve the upper arm vasculature for future use - the forearm loop arteriovenous fistula.
METHODS: From October 2015 to September 2016, 202 patients with chronic kidney disease (CKD), stages 4 and 5, underwent arteriovenous fistula creation at the Universiti Sains Malaysia Hospital, Malaysia. Nine patients, with severe atherosclerosis of the distal artery, but with satisfactory veins, underwent forearm loop arteriovenous fistula creation. Maturation of the fistula was based on the classification by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI).
RESULTS: All nine patients who underwent forearm loop arteriovenous fistula have had diabetes mellitus for more than 10 years. Only one fistula failed to mature within 6 weeks. Two arteriovenous fistulas thrombosed at 3 and 5 months, respectively, after the commencement of haemodialysis. However, the other six matured fistulas are still functioning well after a year of regular usage.
CONCLUSIONS: Distal forearm arteries in diabetics may be severely atherosclerotic. Forearm loop arteriovenous fistula can be considered as the primary access for cases decided as inconvenient for fistula creation due to severe occlusive atherosclerotic disease of the forearm arteries; in order to preserve upper arm veins for future access procedures.

Matched MeSH terms: Thrombosis/etiology
Axillary artery thrombosis associated with fracture of the clavicle

Iqbal QM

Med J Malaya, 1971 Sep;26(1):68-70.
PMID: 4258581
Matched MeSH terms: Thrombosis/etiology*
Fulltext Behcet's disease with vascular complications

Normayah K, Mazri YM, Suib I, Zainal AA

Med J Malaysia, 2004 Oct;59(4):547-9.
PMID: 15779593

A young gentleman presented with a history of multiple pseudoaneurysms of the right carotid artery, left radial artery, right femoral artery as well as deep vein thrombosis involving the right femoral vein. A diagnosis of Behcet's disease was made on the basis of his history of recurrent oral and genital ulceration with characteristic eye lesion.

Matched MeSH terms: Venous Thrombosis/etiology
Bilateral ophthalmic vein thrombosis secondary to nasal furunculosis

Rohana AR, Rosli MK, Nik Rizal NY, Shatriah I, Wan Hazabbah WH

Orbit, 2008;27(3):215-7.
PMID: 18569833 DOI: 10.1080/01676830802009754

We were presented with a teenage female who developed superior ophthalmic vein thrombosis and cavernous sinus thrombophlebitis after a 1-week history of a single acne-like lesion or furuncle at the anterior tip of the nose. She was managed aggressively with heparin and intravenous antibiotic. Signs and symptoms improved after 2 weeks of treatment, and she was discharged with an anticoagulant.

Matched MeSH terms: Cavernous Sinus Thrombosis/etiology*; Venous Thrombosis/etiology*
Fulltext COVID-19 Infection and Circulating Microparticles-Reviewing Evidence as Microthrombogenic Risk Factor for Cerebral Small Vessel Disease

Che Mohd Nassir CMN, Hashim S, Wong KK, Abdul Halim S, Idris NS, Jayabalan N, et al.

Mol Neurobiol, 2021 Aug;58(8):4188-4215.
PMID: 34176095 DOI: 10.1007/s12035-021-02457-z

Severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) due to novel coronavirus disease 2019 (COVID-19) has affected the global society in numerous unprecedented ways, with considerable morbidity and mortality. Both direct and indirect consequences from COVID-19 infection are recognized to give rise to cardio- and cerebrovascular complications. Despite current limited knowledge on COVID-19 pathogenesis, inflammation, endothelial dysfunction, and coagulopathy appear to play critical roles in COVID-19-associated cerebrovascular disease (CVD). One of the major subtypes of CVD is cerebral small vessel disease (CSVD) which represents a spectrum of pathological processes of various etiologies affecting the brain microcirculation that can trigger subsequent neuroinflammation and neurodegeneration. Prevalent with aging, CSVD is a recognized risk factor for stroke, vascular dementia, and Alzheimer's disease. In the background of COVID-19 infection, the heightened cellular activations from inflammations and oxidative stress may result in elevated levels of microthrombogenic extracellular-derived circulating microparticles (MPs). Consequently, MPs could act as pro-coagulant risk factor that may serve as microthrombi for the vulnerable microcirculation in the brain leading to CSVD manifestations. This review aims to appraise the accumulating body of evidence on the plausible impact of COVID-19 infection on the formation of microthrombogenic MPs that could lead to microthrombosis in CSVD manifestations, including occult CSVD which may last well beyond the pandemic era.

Matched MeSH terms: Thrombosis/etiology*
Fulltext COVID-19 and Major Organ Thromboembolism: Manifestations in Neurovascular and Cardiovascular Systems

Pillai P, Joseph JP, Fadzillah NHM, Mahmod M

J Stroke Cerebrovasc Dis, 2021 Jan;30(1):105427.
PMID: 33137615 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105427

COVID-19, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been shown to cause multisystemic damage. We undertook a systematic literature review and comprehensive analysis of a total of 55 articles on arterial and venous thromboembolism in COVID-19 and articles on previous pandemics with respect to thromboembolism and compared the similarities and differences between them. The presence of thrombosis in multiple organ systems points to thromboembolism being an integral component in the pathogenesis of this disease. Thromboembolism is likely to be the main player in the morbidity and mortality of COVID -19 in which the pulmonary system is most severely affected. We also hypothesize that D-dimer values could be used as an early marker for prognostication of disease as it has been seen to be raised even in the pre-symptomatic stage. This further strengthens the notion that thromboembolism prevention is necessary. We also examined literature on the neurovascular and cardiovascular systems, as the manifestation of thromboembolic phenomenon in these two systems varied, suggesting different pathophysiology of damage. Further research into the role of thromboembolism in COVID-19 is important to advance the understanding of the virus, its effects and to tailor treatment accordingly to prevent further casualties from this pandemic.

Matched MeSH terms: Venous Thrombosis/etiology*
Fulltext COVID-19 and hypertension-evidence and practical management: Guidance from the HOPE Asia Network

Kario K, Morisawa Y, Sukonthasarn A, Turana Y, Chia YC, Park S, et al.

J Clin Hypertens (Greenwich), 2020 Jul;22(7):1109-1119.
PMID: 32643874 DOI: 10.1111/jch.13917

There are several risk factors for worse outcomes in patients with coronavirus 2019 disease (COVID-19). Patients with hypertension appear to have a poor prognosis, but there is no direct evidence that hypertension increases the risk of new infection or adverse outcomes independent of age and other risk factors. There is also concern about use of renin-angiotensin system (RAS) inhibitors due to a key role of angiotensin-converting enzyme 2 receptors in the entry of the SARS-CoV-2 virus into cells. However, there is little evidence that use of RAS inhibitors increases the risk of SARS-CoV-2 virus infection or worsens the course of COVID-19. Therefore, antihypertensive therapy with these agents should be continued. In addition to acute respiratory distress syndrome, patients with severe COVID-19 can develop myocardial injury and cytokine storm, resulting in heart failure, arteriovenous thrombosis, and kidney injury. Troponin, N-terminal pro-B-type natriuretic peptide, D-dimer, and serum creatinine are biomarkers for these complications and can be used to monitor patients with COVID-19 and for risk stratification. Other factors that need to be incorporated into patient management strategies during the pandemic include regular exercise to maintain good health status and monitoring of psychological well-being. For the ongoing management of patients with hypertension, telemedicine-based home blood pressure monitoring strategies can facilitate maintenance of good blood pressure control while social distancing is maintained. Overall, multidisciplinary management of COVID-19 based on a rapidly growing body of evidence will help ensure the best possible outcomes for patients, including those with risk factors such as hypertension.

Matched MeSH terms: Thrombosis/etiology
Call for Caution: Neonatal Portal Vein Thrombosis following Enbucrilate Embolization of Placental Chorioangioma

Voon HY, Amin R, Kok JL, Tan KS

Fetal Diagn Ther, 2018;43(1):77-80.
PMID: 28796996 DOI: 10.1159/000479105

We illustrate a case of giant placental chorioangioma presenting at 20 weeks of gestation. Subsequent monitoring revealed enlargement of the lesion, associated with fetal anemia and cardiac failure, prompting in utero intervention. Amnioreduction followed by percutaneous embolization of the tumour with enbucrilate:Lipiodol Ultra-Fluid™ at a dilution of 1:5 was successfully performed. No repeat intervention or additional supportive measures were required throughout pregnancy and the baby was delivered at 36 weeks of gestation, following spontaneous labour. Due to prolonged neonatal jaundice, further investigations were undertaken, demonstrating subacute right portal vein thrombosis. Other previously reported causes of neonatal portal vein thrombosis such as umbilical vein thrombosis, neonatal umbilical vein catheterization, thrombophilia and sepsis were excluded. There was resolution of the thrombus by 6 months of life. A brief discussion of measures to minimize the risk of such an event and the long-term outcomes of neonatal portal vein thrombosis was included. Whilst the simplicity and efficacy of the procedure has been demonstrated in a handful of patients, judgment on its safety is best deferred. Counselling should be comprehensive, as even rare complications can result in significant postnatal morbidity.

Matched MeSH terms: Venous Thrombosis/etiology*
Cavernous sinus thrombosis secondary to sinusitis

Amran M, Sidek DS, Hamzah M, Abdullah JM, Halim AS, Johari MR, et al.

J Otolaryngol, 2002 Jun;31(3):165-9.
PMID: 12121021
Matched MeSH terms: Cavernous Sinus Thrombosis/etiology*
Fulltext Central nervous system Erdheim Chester disease presenting with raised intracranial pressure and cerebellar signs mimicking neurosarcoidosis with secondary cerebral venous thrombosis

Viswanathan S, Kadir NA, Lip AC, Rafia MH

Neurol India, 2014 Jul-Aug;62(4):446-8.
PMID: 25237960 DOI: 10.4103/0028-3886.141250
Matched MeSH terms: Venous Thrombosis/etiology*
Cerebral arterial gas embolism in air force ground maintenance crew--a report of two cases

Lee CT

Aviat Space Environ Med, 1999 Jul;70(7):698-700.
PMID: 10417007

Two cases of cerebral arterial gas embolism (CAGE) occurred after a decompression incident involving five maintenance crew during a cabin leakage system test of a Hercules C-130 aircraft. During the incident, the cabin pressure increased to 8 in Hg (203.2 mm Hg, 27 kPa) above atmospheric pressure causing intense pain in the ears of all the crew inside. The system was rapidly depressurized to ground level. After the incident, one of the crew reported chest discomfort and fatigue. The next morning, he developed a sensation of numbness in the left hand, with persistence of the earlier symptoms. A second crewmember, who only experienced earache and heaviness in the head after the incident, developed retrosternal chest discomfort, restlessness, fatigue and numbness in his left hand the next morning. Both were subsequently referred to a recompression facility 4 d after the incident. Examination by the Diving Medical Officer on duty recorded left-sided hemianesthesia and Grade II middle ear barotrauma as the only abnormalities in both cases. Chest X-rays did not reveal any extra-alveolar gas. Diagnoses of Static Neurological Decompression Illness were made and both patients recompressed on a RN 62 table. The first case recovered fully after two treatments, and the second case after one treatment. Magnetic resonance imaging (MRI) of the brain and bubble contrast echocardiography performed on the first case 6 mo after the incident were reported to be normal. The second case was lost to follow-up. Decompression illness (DCI) generally occurs in occupational groups such as compressed air workers, divers, aviators, and astronauts. This is believed to be the first report of DCI occurring among aircraft's ground maintenance crew.

Matched MeSH terms: Intracranial Embolism and Thrombosis/etiology*
Cerebral venous thrombosis associated with antithrombin III deficiency

Lee MK, Ng SC

Aust N Z J Med, 1991 Oct;21(5):772-3.
PMID: 1759929
Matched MeSH terms: Intracranial Embolism and Thrombosis/etiology
Clinical update on deep vein thrombosis in Singapore

Lee LH

Ann Acad Med Singap, 2002 Mar;31(2):248-52.
PMID: 11957569

Venous thromboembolism (VTE) is thought to be a rare occurrence in Asian patients. The clinical features of VTE are elusive and the disease often unsuspected. Objective testing such as the duplex ultrasound scans and pulmonary imaging are necessary as clinical diagnosis alone is inaccurate. Fatality can occur in untreated patients not suspected of the disease as shown by our post-mortem studies. Indeed VTE is one of the leading causes of maternal mortality in Singapore. There is a rising trend in the incidence of VTE in Asia. Initial studies found an incidence of about 3 per 10,000 hospital admissions in Hong Kong and Malaysia in 1988 and 1990, respectively; rising to 8 and 15.8 per 10,000 hospital admissions in Singapore 1992 and 2000, respectively. The major risk factors for developing deep vein thrombosis (DVT) in our patients are immobilisation, surgery and malignancy. While Factor V Leiden mutation and mutation at position 20,210 in the prothrombin gene are found to be extremely rare in Chinese, the rest of the thrombophilia has not been formally studied. Studies in Singapore reported rates of 3% to 7% of DVT after general surgery, 9.7% after hip surgery and 14% after total knee replacement surgery. It is difficult to compare with studies from other centres because of differences in patient selection and diagnostic criteria. Studies in Singapore showed that the use of prophylactic low molecular weight heparin completely abolished the occurrence of DVT for patients undergoing total knee replacement and colorectal surgery without an increase in bleeding complications. In conclusion, VTE is not an uncommon problem here. Major acquired risk factors do not differ from the Caucasian populations. VTE is a preventable disease and a better understanding of its epidemiology, patient-risk factors and biological factors will allow better management of this condition.

Matched MeSH terms: Venous Thrombosis/etiology
Fulltext Deep vein thrombosis secondary to abdominal aortic aneurysm: A case report

Goh ZNL, Seak JC, Seak CK, Wu CT, Seak CJ

Medicine (Baltimore), 2019 Aug;98(31):e16645.
PMID: 31374036 DOI: 10.1097/MD.0000000000016645

RATIONALE: Abdominal aortic aneurysm is an extremely rare cause of deep vein thrombosis. Here we report an elderly gentleman who presented with deep vein thrombosis and was found to have concomitant abdominal aortic aneurysm upon ultrasonographic screening. It illustrates the possibility of such an aetiology, and the importance of screening for such aneurysms in a select patient population before heparinization.
PATIENT CONCERNS: A 73-year-old Asian gentleman with underlying hypertension, hyperlipidaemia, chronic renal failure, and history of chronic smoking presented to the emergency department with acute left lower limb swelling of 1 day. On examination, the patient was tachycardic (110 beats/minute) and hypertensive (168/84 millimeters mercury (mmHg)). The entire left lower limb was swollen with notable pitting oedema, tenderness, and warmth; left calf swelling was measured to be 4 centimeters (cm).
DIAGNOSES: The patient's Wells score of 4 placed him in the high-risk group for deep vein thrombosis. Serum D-dimer was subsequently found to be elevated at 926 nanograms/milliliter (ng/ml). Compression ultrasonography revealed a thrombus in the left deep femoral vein, confirming the diagnosis of deep vein thrombosis. The ultrasonographic evaluation was extended to the abdominal aorta due to the patient's high risk of abdominal aortic aneurysm, and a 7-cm aneurysm was indeed found. Further computed tomography and magnetic resonance imaging localized it to the infrarenal region, with left common iliac vein compression resulting in stagnant venous return.
INTERVENTIONS: Emergency endovascular repair was performed with insertion of an inferior vena cava filter.
OUTCOMES: The patient was subsequently monitored in the intensive care unit and uneventfully discharged after 2 weeks.
LESSONS: Such clinical presentations of deep vein thrombosis are rare, but physicians are reminded to consider screening for abdominal aneurysms and other anatomical causes before heparinization in patients who seemingly do not have thromboembolic risk factors. This is especially so for the high risk group of male deep vein thrombosis patients aged 65-75 years with a history of smoking who have yet to be screened for abdominal aortic aneurysms, in line with United States Preventive Services Task Force recommendations.

Matched MeSH terms: Venous Thrombosis/etiology*
Deep-vein thrombosis rates after major orthopedic surgery in Asia. An epidemiological study based on postoperative screening with centrally adjudicated bilateral venography

Piovella F, Wang CJ, Lu H, Lee K, Lee LH, Lee WC, et al.

J Thromb Haemost, 2005 Dec;3(12):2664-70.
PMID: 16359505

BACKGROUND: The incidence of postsurgical venous thromboembolism is thought to be low in Asian ethnic populations.
OBJECTIVE: We studied the incidence of deep-vein thrombosis (DVT) in Asian patients undergoing major orthopedic surgery of the lower limbs.
PATIENTS/METHODS: We performed a prospective epidemiological study in 19 centers across Asia (China, Indonesia, South Korea, Malaysia, Philippines, Taiwan, and Thailand) in patients undergoing elective total hip replacement (THR), total knee replacement (TKR) or hip fracture surgery (HFS) without pharmacological thromboprophylaxis. The primary endpoint was the rate of DVT of the lower limbs documented objectively with bilateral ascending venography performed 6-10 days after surgery using a standardized technique and evaluated by a central adjudication committee unaware of local interpretation.
RESULTS: Overall, of 837 Asian patients screened for this survey, 407 (48.6%, aged 20-99 years) undergoing THR (n = 175), TKR (n = 136) or HFS (n = 96) were recruited in 19 centers. DVT was diagnosed in 121 of 295 evaluable patients [41.0%, (95% confidence interval (CI): 35.4-46.7)]. Proximal DVT was found in 30 patients [10.2% (7.0-14.2)]. Total DVT and proximal DVT rates were highest in TKR patients (58.1% and 17.1%, respectively), followed by HFS patients (42.0% and 7.2%, respectively), then THR patients (25.6% and 5.8%, respectively). DVT was more frequent in female patients aged at least 65 years. Pulmonary embolism was clinically suspected in 10 of 407 patients (2.5%) and objectively confirmed in two (0.5%).
CONCLUSIONS: The rate of venographic thrombosis in the absence of thromboprophylaxis after major joint surgery in Asian patients is similar to that previously reported in patients in Western countries.

Matched MeSH terms: Venous Thrombosis/etiology
Definite stent thrombosis among Malaysian population: predictors and insights of mechanisms from intracoronary imaging

Lim KC, Yap LB, Amin AN

Med J Malaysia, 2020 09;75(5):472-478.
PMID: 32918412

INTRODUCTION: Stent thrombosis (ST) is an uncommon, but significant complication following angioplasty. We aimed to examine the predictors, clinical outcomes and mechanism of definite ST cases among patients who underwent percutaneous coronary intervention (PCI).
METHODS: This was a retrospective observational registry of 14,935 patients from the year 2011 till 2015. Clinical characteristics, clinical outcome and intracoronary imaging data were recorded in all the patients. The SPSS Statistic version 24 was used for statistical analysis. The Cox regression hazard model was used to report calculate the hazard ratio (HR) with a 95% confidence interval (95%CI). Independent predictors of ST were identified by univariate logistic regression analysis. Variables that showed a statistically significant effect in univariate analyses were entered in a multivariate Cox proportional hazards model. A p-value<0.05 was regarded as significant.
RESULTS: The incidence of definite ST was 0.25% (37 out of 14935 patients). 75% of ST group patients presented with ST elevation myocardial infarction (75% vs. 19.8%, p<0.01). There was higher mortality among patients with ST when compared to the group without ST (Hazard Ratio, HR=10.69, 95%CI: 1.13, 100). Two independent predictors of ST were 1) previous history of acute myocardial infarction (HR=2.36, 95%CI: 1.19, 4.70) and 2) PCI in the context of acute coronary syndrome when compared to elective PCI (HR=37, 95%CI: 15.7, 91.5). Examination of 19 ST cases with intracoronary imaging identified nine cases (47%) of underexpanded stents and five cases (26%) of malopposition of stents.
CONCLUSIONS: ST is associated with high mortality. PCI in acute coronary syndrome setting and a previous history of acute myocardial infarction were significant predictors for ST. Intracoronary imaging identified stent underexpansion and malopposition as common reasons for ST. In cases where the risk of ST is high, the use of intracoronary imaging guided PCI is recommended.

Matched MeSH terms: Thrombosis/etiology
Dissolution of thrombus formed during direct coronary angioplasty with a single 10 mg intracoronary bolus dose of abciximab

Thuraisingham S, Tan KH

Int J Clin Pract, 1999 Dec;53(8):604-7.
PMID: 10692754

Direct coronary angioplasty with stent implantation is an effective treatment for acute myocardial infarction. The use of adjunctive abciximab, a platelet glycoprotein IIb/IIIa receptor antagonist is expensive. We report on three cases of direct coronary angioplasty complicated by extensive thrombus formation that were successfully treated with attenuated dosing of abciximab via the intracoronary route. All patients presented with acute myocardial infarction complicated by cardiogenic shock or eminent cardiogenic shock. Abciximab was administered after balloon dilatation when extensive thrombus formation was noted and persisted despite repeated inflations. In all three patients a single 10 mg vial of intracoronary abciximab was administered, resulting in complete dissolution of thrombus, allowing successful deployment of stents. Thus, a single 10 mg intracoronary bolus dose of abciximab may be sufficient to achieve high local concentrations of antiplatelet activity. This facilitates thrombus dissolution and allows the safe deployment of a stent to normalise intracoronary rheology.

Matched MeSH terms: Coronary Thrombosis/etiology

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