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A Prospective Study

Gérard Pacouret, MD; Daniel Alison, MD; Jean-Marie Pottier, MD, PhD; Philippe Bertrand, MD; Bernard Charbonnier, MD

Arch Intern Med. 1997;157(3):305-308.

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 lowmolecular-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.

Arch Intern Med. 1997;157:305-308

Author Affiliations
From the Cardiology D and Coronary Care Unit (Drs Pacouret and Charbonnier) and the Departments of Radiology (Drs Alison and Bertrand) and Nuclear Medicine and Ultrasound (Dr Pottier), Trousseau University Hospital, Tours, France.

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