Efficacy of percutaneous mechanical thrombus removal in acute lower extremity deep venous thrombosis

BACKGROUND Acute lower extremity deep venous thrombosis(LEDVT)is a common vascular emergency with significant morbidity risks,including post-thrombotic syndrome(PTS)and pulmonary embolism.Traditional treatments like catheter-directed thrombolysis(CDT)often result in variable success rates and complications.AIM To investigate the therapeutic efficacy of percutaneous mechanical thrombus removal in acute LEDVT.METHODS A retrospective analysis was performed to examine 58 hospitalised patients with acute LEDVT between August 2019 and August 2022.The patients were categorised into the percutaneous mechanical thrombectomy(PMT)group(n=24)and CDT group(n=32).The follow-up,safety and treatment outcomes were compared between the two groups.The main observational indexes were venous patency score,thrombus removal effect,complications,hospitalisation duration and PTS.RESULTS The venous patency score was 9.04±1.40 in the PMT group and 8.81±1.60 in the CDT group,and the thrombus clearance rate was 100%in both groups.The complication rate was 8.33%in the PMT group and 34.84%in the CDT group,and the difference was statistically significant(P<0.05).The average hospitalisation duration was 6.54±2.48 days in the PMT group and 8.14±3.56 days in the CDT group.The incidence of PTS was lower in the PMT group than in the CDT group;however,the difference was not statistically significant(P<0.05).CONCLUSION Compared with CDT,treatment of LEDVT via PMT was associated with a better thrombus clearance rate,clinical therapeutic effect and PTS prevention function,but the difference was not statistically significant.Moreover,PMT was associated with a reduced urokinase dosage,shortened hospitalisation duration and reduced incidence of complications,such as infections and small haemorrhages.These results indicate that PMT has substantial beneficial effects in the treatment of LEDVT.

Clinical Value of Predictive Nursing Intervention on Deep Venous Thrombosis of Lower Extremities after Cesarean Section

[Objectives]To explore the clinical nursing value of predictive nursing intervention in patients with deep venous thrombosis of lower extremities after cesarean section.[Methods]From December 2022 to April 2023,105 pregnant and lying-in women who were hospitalized in the Gynecology Department of Pingquan Hospital and underwent cesarean section and met the inclusion criteria were included as the study objects.According to the medical records,they were divided into observation group(n=52 cases)and control group(n=53 cases).The clinical experimental subjects were divided into two groups.One group was the control group with routine nursing,and the other group was the observation group with predictive nursing intervention.The number of cases of deep venous thrombosis of lower extremities in the two groups was recorded to evaluate the clinical value.[Results]The incidence of deep venous thrombosis of lower extremities in the two groups after cesarean section was compared,and it was suggested that the incidence of the observation group was lower than that of the control group(P<0.05).[Conclusions]Special predictive nursing intervention can greatly reduce the incidence of deep venous thrombosis of lower extremities after cesarean section,improve nursing satisfaction,and improve clinical efficacy,which is worthy of recommendation.

Venous thrombosis and prothrombotic factors in inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) may have an increased risk of venous thrombosis (VTE). PubMed, ISI Web of Knowledge and Scopus were searched to identify studies investigating the risk of VTE and the prevalence of acquired and genetic VTE risk factors and prothrombotic abnormalities in IBD. Overall, IBD patients have a two- to fourfold increased risk of VTE compared with healthy controls, with an overall incidence rate of 1%-8%. The majority of studies did not show significant differences in the risk of VTE between Crohn&#x02019;s disease and ulcerative colitis. Several acquired factors are responsible for the increased risk of VTE in IBD: inflammatory activity, hospitalisation, surgery, pregnancy, disease phenotype (e.g., fistulising disease, colonic involvement and extensive involvement) and drug therapy (mainly steroids). There is also convincing evidence from basic science and from clinical and epidemiological studies that IBD is associated with several prothrombotic abnormalities, including initiation of the coagulation system, downregulation of natural anticoagulant mechanisms, impairment of fibrinolysis, increased platelet count and reactivity and dysfunction of the endothelium. Classical genetic alterations are not generally found more often in IBD patients than in non-IBD patients, suggesting that genetics does not explain the greater risk of VTE in these patients. IBD VTE may have clinical specificities, namely an earlier first episode of VTE in life, high recurrence rate, decreased efficacy of some drugs in preventing further episodes and poor prognosis. Clinicians should be aware of these risks, and adequate prophylactic actions should be taken in patients who have disease activity, are hospitalised, are submitted to surgery or are undergoing treatment.

The effect of nursing intervention based on Autar scale results to reduce deep venous thrombosis incidence in orthopaedic surgery patients

Purpose:To reduce the incidence of deep venous thrombosis(DVT)with nursing intervention based on the Autar DVT risk assessment scale among orthopaedic surgery patients.Methods:We recruited 216 orthopaedic surgery patients at our hospital between September 2013 and March 2014.The patients were assigned to intervention and historical control groups based on the time of admission.Using the Autar DVT risk assessment scale,we assessed the DVT risk levels in both groups;the intervention group received the corresponding prophylactic measures while the control group received routine nursing.Results:The DVT incidence rate and the D-dimer level on postoperative day 3 in the intervention group were lower(1.82%;623±225 mg/L,respectively)than that of the control group(9.43%;825±201 mg/L,respectively);both differences were statistically significant(p<0.05).Conclusions:The Autar scale is beneficial when used in orthopaedic surgery patients;corresponding nursing intervention based on Autar scale assessment can prevent DVT effectively.

Initial transcatheter thrombolysis for acute superior mesenteric venous thrombosis

AIM: To determine the optimal initial treatment modality for acute superior mesenteric vein thrombosis (ASMVT) in patients with circumscribed peritonitis.

Nomogram for predicting transmural bowel infarction in patients with acute superior mesenteric venous thrombosis

BACKGROUND The prognosis of acute mesenteric ischemia(AMI)caused by superior mesenteric venous thrombosis(SMVT)remains undetermined and early detection of transmural bowel infarction(TBI)is crucial.The predisposition to develop TBI is of clinical concern,which can lead to fatal sepsis with hemodynamic instability and multi-organ failure.Early resection of necrotic bowel could improve the prognosis of AMI,however,accurate prediction of TBI remains a challenge for clinicians.When determining the eligibility for explorative laparotomy,the underlying risk factors for bowel infarction should be fully evaluated.AIM To develop and externally validate a nomogram for prediction of TBI in patients with acute SMVT.METHODS Consecutive data from 207 acute SMVT patients at the Wuhan Tongji Hospital and 89 patients at the Guangzhou Nanfang Hospital between July 2005 and December 2018 were included in this study.They were grouped as training and external validation cohort.The 207 cases(training cohort)from Tongji Hospital were divided into TBI and reversible intestinal ischemia groups based on the final therapeutic outcomes.Univariate and multivariate logistic regression analyses were conducted to identify independent risk factors for TBI using the training data,and a nomogram was subsequently developed.The performance of the nomogram was evaluated with respect to discrimination,calibration,and clinical usefulness in the training and external validation cohort.RESULTS Univariate and multivariate logistic regression analyses identified the following independent prognostic factors associated with TBI in the training cohort:The decreased bowel wall enhancement(OR=6.37,P<0.001),rebound tenderness(OR=7.14,P<0.001),serum lactate levels>2 mmol/L(OR=3.14,P=0.009)and previous history of deep venous thrombosis(OR=6.37,P<0.001).Incorporating these four factors,the nomogram achieved good calibration in the training set[area under the receiver operator characteristic curve(AUC)0.860;95%CI:0.771-0.925]and the external validation set(AUC 0.851;95%CI:0.796-0.897).The positive and negative predictive values(95%CIs)of the nomogram were calculated,resulting in positive predictive values of 54.55%(40.07%-68.29%)and 53.85%(43.66%-63.72%)and negative predictive values of 93.33%(82.14%-97.71%)and 92.24%(85.91%-95.86%)for the training and validation cohorts,respectively.Based on the nomogram,patients who had a Nomo-score of more than 90 were considered to have high risk for TBI.Decision curve analysis indicated that the nomogram was clinically useful.CONCLUSION The nomogram achieved an optimal prediction of TBI in patients with AMI.Using the model,the risk for an individual patient inclined to TBI can be assessed,thus providing a rational therapeutic choice.

Predictors of irreversible intestinal resection in patients with acute mesenteric venous thrombosis

BACKGROUND Acute mesenteric venous thrombosis(AMVT)can cause a poor prognosis.Prompt transcatheter thrombolysis(TT)can achieve early mesenteric revascularization.However,irreversible intestinal ischemia still occurs and the mechanism is still unclear.AIM To evaluate the clinical outcomes of and to identify predictive factors for irreversible intestinal ischemia requiring surgical resection in AMVT patients treated by TT.METHODS The records of consecutive patients with AMVT treated by TT from January 2010 to October 2017 were retrospectively analyzed.We compared patients who required resection of irreversible intestinal ischemia to patients who did not require.RESULTS Among 58 patients,prompt TT was carried out 28.5 h after admission.A total of 42(72.4%)patients underwent arteriovenous combined thrombolysis,and 16(27.6%)underwent arterial thrombolysis alone.The overall 30-d mortality rate was 8.6%.Irreversible intestinal ischemia was indicated in 32(55.2%)patients,who had a higher 30-d mortality and a longer in-hospital stay than patients without resection.The significant independent predictors of irreversible intestinal ischemia were Acute Physiology and Chronic Health Evaluation(APACHE)II score(odds ratio=2.368,95% confidence interval:1.047-5.357,P=0.038)and leukocytosis(odds ratio=2.058,95% confidence interval:1.085-3.903,P=0.027).Using the receiver operating characteristic curve,the cutoff values of the APACHE II score and leukocytosis for predicting the onset of irreversible intestinal ischemia were calculated to be 8.5 and 12×10^9/L,respectively.CONCLUSION Prompt TT could achieve a favorable outcome in AMVT patients.High APACHE II score and leukocytosis can significantly predict the occurrence of irreversible intestinal ischemia.Therefore,close monitoring of these factors may help with the early identification of patients with irreversible intestinal ischemia,in whom ultimately surgical resection is required,before the initiation of TT.

Cerebral venous thrombosis and heparin-induced thrombocytopenia in an 18-year old male with severe ulcerative colitis

The risk of thromboembolism is increased in inflammatory bowel disease and its symptoms may be overlooked. Furthermore, its treatment can be complex and is not without complications. We describe a case of an adolescent boy who developed a cerebral sinus venous thrombosis during a relapse of his ulcerative colitis and who, while on treatment with heparin, developed heparin-induced thrombocytopenia (HIT). The treatment was then switched to fondaparinux, a synthetic and selective inhibitor of activated factor .

Clinical Study on Effect of Osteoking (恒古骨伤愈合剂) in Preventing Postoperational Deep Venous Thrombosis in Patients with Intertrochanteric Fracture

Objective： To evaluate the effect of Osteoking （恒古骨伤愈合剂） in preventing postoperational deep venous thrombosis （DVT） in patients with intertrochanteric fracture （ITF）. Methods： With prospective and randomized controlled clinical design adopted, 62 patients with ITF after operation were assigned into 2 groups, the tested group and the control group, Osteoking （25 ml every other day） and Sanchidansheng tablets （三七丹参片, 3 tablets thrice a day） were given orally to them respectively for 10 days. Difference of round length of thighs and shanks between two sides were measured on the 10th day and Doppler ultrasonic examination on the fractured leg was carried out. Results： The occurrence rate of DVT in the tested goup was 9.4%, which was lower than that in the control group （30.0%, P〈0.05）. All the difference of round lengths, either that of the thigh or the shank, was less in the tested group than that in the control group, showing statistical significance （P〈0.05）. Conclusion： Osteoking has a satisfactory effect in preventing postoperational DVT in patients with ITF.

Two-point compression ultrasonography: Enough to rule out lower extremity deep venous thrombosis?

BACKGROUND: Deep venous thrombosis(DVT) is a major cause of morbidity and is a common presenting complaint to the emergency department(ED). Point-of-care two-point compression ultrasonography has evolved as a quick and effective way of diagnosing DVT. The purpose of this study is to validate the prevalence and distribution of venous thrombi isolated to proximal lower extremity veins, other than common femoral and popliteal veins in patients with DVT.METHODS: This is a single-center retrospective study that looked at patients presenting to the ED of a tertiary care hospital between January 2014 and August 2018. The clinical presentation and laboratory and imaging results were obtained using the hospital's electronic medical record.RESULTS: A total of 2,507 patients underwent a lower extremity duplex ultrasound during the study period. Among them, 379(15%) were included in the study. The percentages of isolated thrombi to the femoral vein and deep femoral vein were 7.92% and 0.53%, respectively. When the patients were stratified into the two groups of isolated DVT and two-point compression DVT, there were no statistically significant differences in the laboratory results between both groups. However, immobilized patients and patients with recent surgeries were more likely to have an isolated DVT.CONCLUSIONS: Thrombi isolated to proximal lower extremity veins other than the common femoral and popliteal veins make up 8.45% of DVTs. Given this significant number of missed DVTs, the authors recommend the addition of the femoral and deep femoral veins to the two-point compression exam.

Combined MR Imaging for Pulmonary Embolism and Deep Venous Thrombosis by Contrast-enhanced MR Volume Interpolated Body Examination

MR pulmonary angiography(MRPA)combined with indirect MR venography(MRV)was attempted by using 3D contrast-enhanced MR volume interpolated body examination(VIBE)sequence.Agreement rate for deep venous thrombosis(DVT)detection between MRV and duplex sonography(DUS)was evaluated;the potential of this method for venous thromoembolism(VTE)was also investigated.Thirty-four patients with DUS-identified DVT were enrolled in this study.MRI was performed after a single administration of Gadopentetate dimeglumine.Fatsuppressed 3D VIBE was applied for visualizing pulmonary arteries,abdominal veins,pelvic and leg veins,ranging from lung apex to ankle level.Two radiologists observed the MR images in consensus,recorded the location and number of emboli.MRV images were assessed based on per-vein segment.The agreement rate between MRV and DUS for venous segment-to-segment comparison was analyzed by Wilcoxon rank sum test.All the patients were diagnosed as having DV 1 by MRV.MRV detected 55 more venous segments with thrombi than DUS based on per-vein segment analysis.Twenty-three patients with pulmonary embolism(PE)were detected by MRPA.Twenty-one patients underwent both pulmonary CT angiography and MRPA,and consistency for PE detection was 100%.Total examination time of the combined MR protocol was 7 min for each patient.The contrast-enhanced VIBE sequence proves to be a feasible and reliable method for VTE diagnosis in one-stop MR scanning procedure,and contrast-enhanced VIBE performs better to depict DVT than DUS on per-vein segment basis.

Cerebral venous thrombosis presenting with headache only and misdiagnosed as subarachnoid hemorrhage

Patients with headache constitute up to 4.5% of emergency department （ED） visits.~11 Cerebral venous thrombosis （CVT） is an important cause of the headache that is more common than once suspected. The diagnosis of CVT is often missed or delayed because of non- specific clinical manifestations, and brain computerized tomography （CT） may easily be misinterpreted.

Acute pulmonary embolism originating from upper limb venous thrombosis following breast cancer surgery:Two case reports

BACKGROUND Upper limb venous thrombosis(ULVT)is rarer than lower-extremity deep venous thrombosis,and is related to Paget-Schroetter syndrome,central venous catheterization,and malignancy.There are few reports of pulmonary embolism(PE)from upper-extremity vein thrombosis due to surgery.Herein,we report two cases of PE that originated from upper limb venous thrombosis on the surgical side in two patients undergoing modified radical mastectomy for breast cancer.These cases challenge the traditional theory that PE originate only from the lower extremities.CASE SUMMARY We describe two female patients,aged 68 and 65 years,respectively,who had undergone modified radical mastectomy for breast cancer.They did not have a central venous catheter and did not undergo preoperative neoadjuvant chemotherapy.They were transferred to the intensive care unit due to symptomatic PE on the first day after surgery.Colour Doppler ultrasound identified fresh thrombosis in their upper limb veins,which was the presumed source of the PE.They all received anticoagulation therapy,and one of them experienced bleeding that required discontinuation of the drug.Ultimately,they were discharged in stable condition.CONCLUSION ULVT as a source of PE after breast cancer surgery cannot be ignored.

Effect of Physical Intervention on Preventing Upper Limb Venous Thrombosis of Patients with PICC: A Systematic Review and Meta-Analysis of Randomized Trials

Objective: To evaluate the effect of physical methods on the prevention of venous thrombosis in patients with peripherally inserted central catheter (PICC). Methods: Randomized controlled trials meeting the inclusion and exclusion criteria were retrieved from the following databases: Cochrane library, Pubmed, EMbase, Web of science, Ovid, CBM, CNKI, Wanfang, VIP, then Review Manage (RevMan) 5.3 software was used for data analysis. Results: A total of 24 RCTs including 3496 patients were analyzed in the study. The results of meta-analysis showed that various forms of upper limb movements could effectively decrease the incidence of venous thrombosis in the patients with PICC [RR = 0.23, 95% CI (0.16, 0.33), P < 0.01], upper limb movements could effectively improve the mean blood flow velocity of basilic vein [MD = 1.65, 95% CI (1.19, 2.11), P < 0.01]. Conclusion: Upper limb movements can effectively decrease the incidence of phlebothrombosis and improve the mean flow velocity of basilic vein in the patients undergoing PICC. Other forms of physical prevention methods need to be further studied due to insufficient sample size.

Comparison of four clinical scores for the predicting lower limb deep venous thrombosis in Chinese patients

Objective：To evaluate Wells, Kahn, St.Andr 6 and Constans scores for the prediction of deep venous thrombosis in Chinese patients. Methods：One hundred and seventy-two patients, prospectively, blinded referred for evaluation with four clinical-score systems for suspected deep venous thrombosis, were examined by ultrasonography. Sensitivity, specificity, positive predictive value, negative predictive value and receiver operation curves were calculated for four clinical scores. The difference between areas of the ROC curve for each of the scores was compared with others and reference line. Results：Forty-six of 172 patients had deep venous thrombosis proven by sonography. The sensitivity, specificity, positive predictive value and negative predictive value for Wells score was 91.3%, 57.1%, 43.8% and 94.7%, respectively, for Kahn score; 65.2%, 71.4%, 45.5% and 84.9%, respectively, for St.Andr 6 score; 63%, 38.9%, 27.4% and 74.2% respectively, for Constans score; 95.7%, 34.9%, 34.9% and 95.7% respectively. Area under ROV curve of Constans score was 0.814, which was similar to that of Wells score, then followed by Kahn score and that of St.Andr 6 score was no difference with the reference line. Conclusion：Based on the results of our study, the sensitivity, negative prediction value and area under ROC curve are larger for Constans score and Wells score in Chinese hospitalized patients than that of Kahn score or St.Andr 6 score. Considering the aim of the clinical assessment, Constans score and Wells score are more efficient for Chinese hospitalized patients.

Dabigatran in the Treatment of Extensive Cerebral Venous Thrombosis:A Case Report

Background: Cerebral venous thrombosis (CVT) is a rare type of cerebrovascular disease associated with a 15% rate of death or function dependence. The mainstay of treatment for CVT is systemic anticoagulation, despite venous hemorrhagic infarction. Vitamin K antagonists have long been the only available option for anticoagulation;however, the past few years have brought the development of many new target-specific drugs, collectively called non-vitamin K antagonist oral anticoagulants (NOACs). Although emerging evidence suggests NOACs have an acceptable safety and tolerability profile in CVT, there are limited data available and no randomized controlled trials have been performed to date. Case Presentation: This describes the case of a patient with CVT occurring during an infection who was successfully treated with a NOAC, dabigatran, after a difficult time on warfarin. Conclusions: A case of extensive and deep CVT was identified. Dabigatran 150 mg treatment twice daily in this patient resulted in no additional damage to the brain. This case study illustrates that the use of NOACs such as dabigatran can be safe and effective in patients with CVT.

Imaging characteristics of two patients with isolated cortical venous thrombosis

Over the past twenty years, improvements in neuroimaging have greatly improved the ability to diagnose cerebral venous sinus thrombosis, as well as isolated cortical venous thrombosis. Neuroimaging allows for variations to be detected in the cortical vein and venous sinus. Diagnosis of thromboses in the venous system should not depend entirely on angiography of undeveloped veins or venous sinus. Currently, the combination of magnetic resonance imaging and magnetic resonance venography is the gold standard for diagnosing cerebral venous sinus thrombosis, rather than digital subtraction angiography. This article summarizes clinical manifestations, results from computed tomography and magnetic resonance imaging in two cases of isolated cortical venous thrombosis, analyzed relevant literature, and discussed the clinical and imaging characteristics of isolated cortical venous thromboses.

Carbohydrate Antigens as Potential Biomarkers for the Malignancy in Patients with Idiopathic Deep Venous Thrombosis:A Retrospective Cohort Study

A variety of biomarkers have been identified in recent prospective and retrospective re- ports as being potentially predictive of venous thromboembolis （VTE）, particularly idiopathic deep venous thrombosis （IDVT）. This study identified a serum tumor biomarker for early screening of IDVT. A total of 128 IDVT patients （54 females and 74 males; average age： 50.9＋17.4 years） were included. Carcinoembryonic antigen （CEA）, ferritin, β2-microglobulin, cancer antigen （CA） 125, CA 15-3, CA 19-9, squamous cell carcinoma antigen （SCC）, alpha-fetoprotein （AFP）, prostate specific antigen （PSA）, free PSA （f-PSA）, and beta-human chorionic gonadotropin （13-HCG） in patients with IDVT were detected. Malignancies were histo- or cytopathologically confirmed. Of the 128 IDVT patients, 16 （12.5%） were found to have malignarteies. Serum CEA, CA 125, CA 15-3, and CA 19-9 were found to be helpful for detecting malignancies in IDVT patients. Our study revealed a positive association between these markers and tumors in IDVT patients. On the other hand, SCC and AFP were not sensitive enough to be markers for detecting tumors in patients with IDVT. No significant differences were found in positive rates of ferritin and 132-microglobulin between turnor and non-ttmaor groups, and no significant difference exists in serum levels of ferritin and 132-microglobulin between the two groups. Carbohydrate antigens, CA 15-3 in particular, may be useful for differential diagnosis and prediction of malignancies in patients with IDVT.

Superior mesenteric venous thrombosis: Endovascular management and outcomes

BACKGROUND Superior mesenteric venous thrombosis(SMVT)is a rare but fatal condition that is typically treated initially with anticoagulation therapy,and if this fails,with endovascular interventions.However,due to its rarity,there are not many studies that have explored the effectiveness of anticoagulation and endovascular therapies in treating SMVT.AIM To evaluate patients diagnosed with SMVT who received endovascular therapy in addition to anticoagulation and report technical and clinical outcomes.METHODS A retrospective analysis of the patients who underwent endovascular treatment for SMVT at Mayo Clinic from 2000-2019 was performed.Technical success was defined as angiographic improvement in SMV flow after intervention.Primary patency was defined as the interval from reestablishing mesenteric venous flow until the first repeat thrombotic event or need for additional intervention.Secondary patency was defined as successful restoration of flow after repeat intervention until rethrombosis or last follow-up.The adverse events were reported through Clavien-Dindo classification.RESULTS Twenty-four patients were included for analysis.The median age at intervention was 60 years(35-74 years)and 16(67%)were men.Nineteen patients presented with acute thrombosis(79.2%)and 5 with chronic thrombosis with acute manifestations(20.8%).The most commonly used endovascular modalities were thrombectomy in 12 patients(50.0%)and catheter-directed thrombolysis in 10 patients(41.7%).Technical success was achieved in 18 patients(75%).The 14-d and 30-d primary patency rates were 88.9%and 83.3%,respectively.Adverse events were reported in two patients(8.3%),one marked as grade IIIB,and 1 death marked as grade V.Five-year overall survival rate was 82%(58%-100%).CONCLUSION Endovascular intervention with anticoagulation appears to be effective for managing SMVT.This treatment combination may be considered as first-line therapy for SMVT management in select patients.

Acute deep venous thrombosis induced by May-Thurner syndrome after spondylolisthesis surgery:A case report and review of literature

BACKGROUND Deep venous thrombosis(DVT)is a serious complication of lumbar spine surgery.Current guidelines recommend pharmacomechanical prophylaxis for patients at high risk of DVT after spine surgery.May-Thurner syndrome(MTS),a venous anatomical variation that may require invasive intervention,is an often overlooked cause of DVT.To date,no case reports of symptomatic MTS caused by isthmic spondylolisthesis or subsequent acute DVT after posterior lumbar surgery have been published.CASE SUMMARY We here present a case of a patient who developed acute DVT 4 h after spondylolisthesis surgery,and MTS was only considered after surgery,during a review of a gynecological enhanced computed tomography image taken before the procedure.CONCLUSION In conclusion,clinicians should consider MTS in the presence of a dangerous triad:spondylolisthesis,elevated D-dimer levels,and sonographically indicated unilateral deep vein dilation.Consultation with a vascular surgeon is also essential to MTS management.