title: Free-floating thrombus and embolic risk in patients with angiographically confirmed proximal deep venous thrombosis. A prospective study.
abstract: BACKGROUND
  A free-floating thrombus (FFT) is often considered to be a risk factor for pulmonary embolism (PE), despite adequate anticoagulation therapy, in patients with proximal deep venous thrombosis.
  
  
  METHODS
  Ninety-five patients underwent prospective assessment according to the presence (FFT group [n = 62]) or absence (occlusive thrombus group [n = 28]) of an FFT. On day 1, color venous duplex scanning, venography (reference method), perfusion lung scanning, and, if results of the lung scan were abnormal, pulmonary angiography were performed. On day 10 (range, days 9-11), the lung scan was repeated, as well as pulmonary angiography if the lung scan demonstrated impairment. A 3-month clinical follow-up visit was scheduled. Five patients were retrospectively excluded from analysis for uncertain diagnosis of FFT. Patients were treated with intravenous unfractionated heparin sodium adjusted for activated partial thromboplastin time (n = 1) or subcutaneous low-molecular-weight heparin (n = 89) (nadroparin calcium, 225 Institut Choay factor Xa inhibitory units per kilogram for 12 hours). Warfarin sodium therapy was initiated on day 3 (range, days 2-4).
  
  
  RESULTS
  Both groups were well-matched according to age, sex, risk factors, and delay from onset of symptoms to treatment. Positive and negative predictive values of color venous duplex scanning for the diagnosis of an FFT were 91% and 55%, respectively. On admission, PE prevalence was 64% in the FFT group (40 of 62 patients) and 50% in the occlusive thrombus group (14 of 28 patients) (P = .19). Two patients were excluded on follow-up analysis (range, days 9-11) for preventive vena cava filtering (due to major bleeding in 1 and cholecystectomy in the other); the recurrent rate of PE was 3.3% in the FFT group (2 of 61 patients) and 3.7% in the occlusive thrombus group (1 of 27 patients). No symptomatic recurrent PE occurred between day 10 (range, days 9-11) and 3 months. Four patients died of evolutive neoplasm after hospital discharge.
  
  
  CONCLUSIONS
  No higher risk for PE was observed in patients with free-floating proximal deep venous thrombosis; anticoagulant therapy should prevent recurrent PE in such patients.
authors.affiliation: Cardiology D and Coronary Care Unit, Trousseau University Hospital, Tours, France.
authors.forename: G
authors.initials: G
authors.lastname: Pacouret
authors.forename: D
authors.initials: D
authors.lastname: Alison
authors.forename: J M
authors.initials: JM
authors.lastname: Pottier
authors.forename: P
authors.initials: P
authors.lastname: Bertrand
authors.forename: B
authors.initials: B
authors.lastname: Charbonnier
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D004617:Embolism / Q000188:drug therapy / Q000209:etiology* / Q000401:mortality / Q000517:prevention & control; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010690:Phlebography; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012306:Risk; D012307:Risk Factors; D013927:Thrombosis / Q000150:complications* / Q000000981:diagnostic imaging*; D016896:Treatment Outcome