SCIENTIFIC PAPERS
Hypercoagulability
in Patients with
Peripheral Vascular Disease George J. Colltns, Jr, MD,* Denver, Colorado Robert L. Heymann, MD,+ Denver, Colorado Russ Zajtchuk, MD, Denver, Colorado
Hypercoagulability has been the subject of considerable concern in medicine for a number of years, and many investigators have devoted much time and energy to determining whether hypercoagulability as a clinical entity truly exists. In 1943, deTakats [I] used the heparin tolerance test to demonstrate that a number of patients with Buerger’s disease, recent cerebrovascular accident, myocardial infarction, deep vein thrombosis, and arterial thrombosis were hyporeactive to heparin. They were, therefore, considered to be hypercoagulable. In 1960, similar observations were made by Spittel et al [2] using the thromboplastin generation test. In 1964, von Kaulla and von Kaulla [3] described the thrombin generation test and reported accelerated thrombin generation in several patients with a variety of cardiac diseases. More recently, interest has been focused on the presumed ability of oral contraceptives to induce hypercoagulability and, thereby, predispose to thrombotic complications. In 1967, von Kaulla and von Kaulla [4] described a test for determining serum levels of antithrombin III, an alpha-2-glob-
From the Department of General Surgery, Fitzsimons Army Medical Center. Denver, Colorado. * Present address and address for reprint requests: Peripheral Vascutar Surgery Service, Waiter Reed ArmyMedical Center,Washington, DC
20012. +Present
2
address: Washington Medical Center, Washington. Indiina.
ulin, which measures the subject’s protective mechanism against thrombin formation. In 1971, Zuck, Raymond, and Dwyre [5] demonstrated severe suppression of antithrombin III in some women taking oral contraceptives and noted thrombotic complications in a number of such patients. Zuck and Bergin [6] have also demonstrated accelerated thrombin generation and depressed antithrombin III levels in a number of patients with arterial or venous thrombosis. Because some patients undergoing Peripheral vascular reconstruction seem to have inordinate difficulty with thrombotic complications, we studied the coagulation profiles in a number of such patients to determine whether laboratory evidence of hypercoagulability correlated with an increased incidence of thrombotic complications. The tests of thrombin generation and antithrombin III levels were considered the most important for predicting hypercoagulability. Material and Methods A battery of tests, as suggested by van Kaulla, von Kaulla, and Droegemueller--[7], including hematocrit, rxothrombin time. activated martial thrombonlastin time, thrombin generation, antithrombin III values, platelet adhesitivity, and factor VIII values, were performed according to established technics in the coagulation laboratory of Fitzsimons Army Medical Center. Thirty-five patients were studied, but the profile was in-
The American Journal of Surgery
Hypercoagulability
complete in eight and thus twenty-seven patients are in-
cluded in this report. Four arbitrary criteria for suspected hypercoagulability were established: (1) evidence of severe peripheral vascular disease at an age younger than thirty years; (2) failure of one or more previous peripheral vascular reconstructive procedures; (3) postoperative arterial or venous thromboembolism; (4) inadvisability of vascular reconstruction due to poor distal outflow. Patients were then assigned to two groups depending on whether they met any of these arbitrary criteria. In addition, an arbitrary group of operative complications was established: (1) thrombosis of arterial repair; (2) postoperative stroke or myocardial infarction; (3) postoperative venous thrombosis with or without embolism; (4) amputation. Patients were again assigned to groups depending on whether they met any of these arbitrary criteria for operative complications.
generation index of 51.4 in the group without operative complications and that of 66.1 in the group with operative complications. Similarly, there was a statistically significant difference (p
Hypercoagulability
in Patients with
Peripheral Vascular Disease George J. Colltns, Jr, MD,* Denver, Colorado Robert L. Heymann, MD,+ Denver, Colorado Russ Zajtchuk, MD, Denver, Colorado
Hypercoagulability has been the subject of considerable concern in medicine for a number of years, and many investigators have devoted much time and energy to determining whether hypercoagulability as a clinical entity truly exists. In 1943, deTakats [I] used the heparin tolerance test to demonstrate that a number of patients with Buerger’s disease, recent cerebrovascular accident, myocardial infarction, deep vein thrombosis, and arterial thrombosis were hyporeactive to heparin. They were, therefore, considered to be hypercoagulable. In 1960, similar observations were made by Spittel et al [2] using the thromboplastin generation test. In 1964, von Kaulla and von Kaulla [3] described the thrombin generation test and reported accelerated thrombin generation in several patients with a variety of cardiac diseases. More recently, interest has been focused on the presumed ability of oral contraceptives to induce hypercoagulability and, thereby, predispose to thrombotic complications. In 1967, von Kaulla and von Kaulla [4] described a test for determining serum levels of antithrombin III, an alpha-2-glob-
From the Department of General Surgery, Fitzsimons Army Medical Center. Denver, Colorado. * Present address and address for reprint requests: Peripheral Vascutar Surgery Service, Waiter Reed ArmyMedical Center,Washington, DC
20012. +Present
2
address: Washington Medical Center, Washington. Indiina.
ulin, which measures the subject’s protective mechanism against thrombin formation. In 1971, Zuck, Raymond, and Dwyre [5] demonstrated severe suppression of antithrombin III in some women taking oral contraceptives and noted thrombotic complications in a number of such patients. Zuck and Bergin [6] have also demonstrated accelerated thrombin generation and depressed antithrombin III levels in a number of patients with arterial or venous thrombosis. Because some patients undergoing Peripheral vascular reconstruction seem to have inordinate difficulty with thrombotic complications, we studied the coagulation profiles in a number of such patients to determine whether laboratory evidence of hypercoagulability correlated with an increased incidence of thrombotic complications. The tests of thrombin generation and antithrombin III levels were considered the most important for predicting hypercoagulability. Material and Methods A battery of tests, as suggested by van Kaulla, von Kaulla, and Droegemueller--[7], including hematocrit, rxothrombin time. activated martial thrombonlastin time, thrombin generation, antithrombin III values, platelet adhesitivity, and factor VIII values, were performed according to established technics in the coagulation laboratory of Fitzsimons Army Medical Center. Thirty-five patients were studied, but the profile was in-
The American Journal of Surgery
Hypercoagulability
complete in eight and thus twenty-seven patients are in-
cluded in this report. Four arbitrary criteria for suspected hypercoagulability were established: (1) evidence of severe peripheral vascular disease at an age younger than thirty years; (2) failure of one or more previous peripheral vascular reconstructive procedures; (3) postoperative arterial or venous thromboembolism; (4) inadvisability of vascular reconstruction due to poor distal outflow. Patients were then assigned to two groups depending on whether they met any of these arbitrary criteria. In addition, an arbitrary group of operative complications was established: (1) thrombosis of arterial repair; (2) postoperative stroke or myocardial infarction; (3) postoperative venous thrombosis with or without embolism; (4) amputation. Patients were again assigned to groups depending on whether they met any of these arbitrary criteria for operative complications.
generation index of 51.4 in the group without operative complications and that of 66.1 in the group with operative complications. Similarly, there was a statistically significant difference (p
