Search Results (312)

Background: The use of estrogen-based gender-affirming hormone therapy (E-GAHT) has been associated with an increased risk of venous thromboembolism (VTE), but much of the evidence originates from data on cisgender women and from cohorts of transgender and gender diverse (TGD) individuals treated with older estrogen or estrogen/progesterone preparations, often at higher doses. Data on VTE risks associated with more modern E-GAHT regimens in TGD populations are scarce. Methods: A retrospective cohort study of adult TGD individuals who received E-GAHT within the Duke University Health System between January 1996 and June 2025 was conducted. The Duke Enterprise Data Unified Content Explorer (DEDUCE), a Duke electronic medical record search tool, was utilized to identify a cohort of TGD individuals who were prescribed E-GAHT. From this cohort, individuals who experienced a VTE during E-GAHT exposure were identified. Demographic characteristics and comorbidities were compared between the overall study cohort and those who experienced VTE using the SlicerDicer tool within Epic, supplemented by manual chart review. Results: Among 1173 adult TGD individuals prescribed E-GAHT, 16 (1.4%) experienced a VTE. Of these, 11 (68.8%) experienced a pulmonary embolism (PE with/without deep vein thrombosis [DVT]) and five (31.3%) experienced a DVT alone. Among the 16 patients with VTE, six (37.5%) had a transient surgical risk factor prior to VTE, three (18%) had significant non-surgical risk factors, and one (6%) had cancer. The remaining six (37.5%) patients experienced an unprovoked VTE. Patients with VTE were significantly older than the general population of TGD adults and were significantly more likely to experience hypertension, hyperlipidemia, and type 2 diabetes mellitus, compared to TGD patients without VTE. Conclusions: In this retrospective cohort, the proportion of TGD individuals on E-GAHT with VTE was lower than previously reported in the literature. Most events occurred in the presence of other established risk factors, suggesting that E-GAHT itself may confer a lower VTE risk than previously assumed. Larger prospective studies that evaluate both estrogen-specific and patient-specific risk factors are needed to clarify VTE risk in this population. Full article

Cancer-associated thrombosis (CAT) is a leading cause of morbidity and mortality in patients with malignancy, yet its imaging manifestations extend far beyond the conventional diagnosis of deep vein thrombosis and pulmonary embolism. This comprehensive review examines the full spectrum of CAT as encountered by radiologists, from routine venous thromboembolism to unusual-site thromboses, arterial thromboembolic events, catheter-related complications, and endovascular management strategies. Patients with cancer face a four- to seven-fold increased risk of venous thromboembolism compared with the general population, and arterial thromboembolism occurs at more than twice the expected rate, particularly within the first six months following cancer diagnosis. The radiologist’s role spans detection, characterization, and therapeutic guidance across multiple vascular territories. Key diagnostic challenges addressed include the distinction between bland and tumor thrombus—a determination with direct implications for TNM staging, surgical planning, and systemic therapy selection—and the recognition of incidental thromboembolism, which carries prognostic weight equivalent to symptomatic events and warrants similar clinical management. Emerging applications of diffusion-weighted MRI, contrast-enhanced ultrasound, and FDG-PET/CT provide a multiparametric toolkit for thrombus characterization, while artificial intelligence and machine learning show promise for improving patient selection and reducing unnecessary imaging. The expanding recognition of cancer-associated arterial disease, including cerebrovascular, coronary, and peripheral arterial events, requires that cardiovascular structures receive systematic attention on routine oncologic imaging. Interventional radiology contributes actively to CAT management through inferior vena cava filtration, catheter-directed thrombolysis, and thrombolytic-sparing mechanical thrombectomy, the latter being particularly relevant in oncology patients with elevated bleeding risk. Conclusions: Realizing the full potential of imaging in CAT requires not only technical proficiency with individual modalities but a synthesized, oncology-informed interpretive approach that incorporates the patient’s treatment history, biomarker status, and thrombotic risk profile at the time of image interpretation, positioning the radiologist as a central rather than peripheral figure in oncologic care. Full article

Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is a prevalent condition with a significant annual incidence, particularly increasing with age. Its pathophysiology is explained by Virchow’s triad (venous stasis, vascular injury, and hypercoagulability). Tirzepatide, a dual receptor agonist of glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1), is approved for type 2 diabetes mellitus (T2DM) and obesity, showing efficacy in lowering HbA_1c and promoting weight loss. Recent case reports have linked tirzepatide to VTE events, particularly in patients experiencing significant weight loss, raising concerns about its safety profile. We present a case of a male T2DM subject who developed PE after five injections of tirzepatide in a patient with grade I obesity. We also review emerging literature on VTE associated with tirzepatide, emphasizing the need for further research to clarify the drug’s risk and underlying mechanisms. Full article

Functionally single-ventricle (FSV) defects are complex congenital heart anomalies that require Fontan palliation, a surgical procedure redirecting systemic venous blood directly to the pulmonary arteries, bypassing the heart. Despite improvements in surgical techniques and perioperative care leading to enhanced survival rates, patients remain vulnerable to significant long-term complications, due to the unique Fontan circulation physiology. This circulation relies on low pulmonary vascular resistance and preserved single-ventricle function but predisposes patients to venous congestion and reduced cardiac output, resulting in multi-organ dysfunction. Key cardiovascular complications include systolic and diastolic dysfunction of the single ventricle, atrioventricular valve regurgitation, arrhythmias, pulmonary vascular disease, and thromboembolic events. Systemic complications encompass Fontan-associated liver disease (FALD), protein-losing enteropathy (PLE), plastic bronchitis (PB), renal impairment, and endocrine and psychosocial burdens. All the problems induce frequent hospitalizations, psychological challenges, and impaired educational and employment opportunities. Comprehensive management requires multidisciplinary approaches addressing the complex interplay of hemodynamic, organ-specific problems, and psychosocial factors inherent to Fontan physiology. Full article

Transcatheter structural heart interventions, including aortic, mitral and tricuspid valve replacement or repair, and patent foramen ovale, atrial septal defect, and left atrial appendage closure, have dramatically expanded over the past two decades, providing substantial improvements in both clinical outcomes and quality of life. These interventions are performed in a high-risk patient population, which is at risk for both thrombotic and bleeding complications. The introduction of prosthetic devices into the arterial or venous circulation under heterogeneous hemodynamic conditions inevitably increases the risk for thrombotic events and thromboembolic complications. Consequently, the selection of antithrombotic therapy (AT) regimen and its duration is complex and should be tailored to each patient’s risk profile, balancing the expected risk and benefits. This state-of-the-art review critically examines the thrombotic risks inherent to transcatheter structural heart interventions, synthesizes available evidence and current guidelines recommendations on antithrombotic management, and defines persisting gaps in knowledge while discussing the most relevant ongoing clinical trials. Full article

Hormonal contraception is used by hundreds of millions of women worldwide and remains one of the most effective reversible methods of pregnancy prevention. Cardiovascular (CV) safety concerns, particularly venous thromboembolism (VTE), ischemic stroke, myocardial infarction, and blood pressure elevation, are important considerations when choosing forms of contraception. Estrogen-containing combined hormonal contraceptives (CHCs) increase the relative risk of VTE; however, among healthy young nonsmokers, absolute event rates remain low. Risk is strongly modified by estrogen dose, progestin type, route of administration, and individual factors such as age, smoking, migraine with aura, hypertension, obesity, inherited thrombophilia, the postpartum period, and concomitant prothrombotic medications. Progestin-only contraceptives and levonorgestrel-releasing intrauterine systems (LNG-IUSs) generally show a more favorable thrombotic profile and are preferred options for women with contraindications for estrogen. This review summarizes current evidence on the method-specific CV risks of hormonal contraception, highlights the mechanisms underlying these effects, and provides practical guidance for clinical decision-making. Full article

Venous thromboembolism (VTE), comprising deep vein thrombosis and pulmonary embolism, is an important but under-recognised complication in neuromuscular diseases. In adults, emerging epidemiological data suggests increased VTE occurrence in conditions such as Amyotrophic Lateral Sclerosis, myotonic dystrophy, myasthenia gravis, inflammatory neuropathies, inflammatory myopathies, and POEMS syndrome. This heightened risk reflects not only disease-related immobility but also disorder-specific biological mechanisms, including inflammation, endothelial dysfunction and cardiomyopathy-related stasis. Therapies such as corticosteroids, IVIG-related hyperviscosity, long-term central venous access, perioperative immobility, critical illness, and complex orthopaedic procedures have prothrombotic effects. Despite this multifactorial risk profile, disease-specific guidance for thromboprophylaxis is lacking, and current practice relies heavily on extrapolation from general medical and surgical recommendations rather than data derived from neuromuscular cohorts. In children and adolescents, the VTE burden is less well-characterised, but events have been reported in Duchenne and Becker muscular dystrophy, congenital myopathies, and spinal muscular atrophy particularly with advanced motor impairment, severe cardiomyopathy, ventilatory insufficiency, and prolonged hospitalisation. Beyond venous events, selected neuromuscular disorders also exhibit increased arterial thrombosis risk. Myotonic dystrophy and dystrophinopathies are associated with cardiomyopathy and arrhythmia that predispose to systemic embolism and stroke, while inflammatory myopathies may demonstrate arterial events related to vasculitic or endothelial processes, although overall evidence remains limited. This review summarises available empirical and epidemiological evidence on venous and arterial thrombosis across adult and paediatric neuromuscular disorders, outlines disease-specific mechanistic pathways, examines treatment-related contributors, and highlights key evidence gaps that must be addressed to guide rational and targeted prophylaxis strategies in this complex, heterogeneous population. Full article

Background: Venous thromboembolism (VTE) is a common and serious complication in patients with advanced non-small-cell lung cancer (NSCLC). While guidelines recommend prophylactic anticoagulation for cancer outpatients at high risk, its clinical implementation remains conservative in China. Objectives: This study aimed to investigate the current use of prophylactic anticoagulation for advanced NSCLC outpatients at high risk of VTE in China and explore factors influencing physicians’ decision-making. Methods: A descriptive cross-sectional survey using a convenience sampling approach was conducted from May to June 2025 among physicians from multiple top-tier tertiary hospitals across China. The survey assessed physicians’ knowledge, practices, and concerns regarding VTE risk assessment and prophylactic anticoagulation. Descriptive statistics and multiple response analyses were performed using SPSS 25.0. Results: A total of 235 valid responses were collected. Although 84.7% of physicians reported receiving anticoagulation training, only 57.8% routinely used the Khorana score for risk assessment. After excluding six physicians (2.7%) who reported never assessing VTE risk, 59.4% reported initiating prophylactic anticoagulation for patients with a Khorana score ≥ 2. Direct oral anticoagulants were preferred by 75.6% of physicians. Key concerns included management of bleeding events (78.6%) and adverse reactions monitoring (61.1%). Notably, only 49.4% of physicians reported being familiar with the Khorana score. Conclusions: Prophylactic anticoagulation for advanced NSCLC outpatients appears to remain underutilized in China. Limited familiarity with VTE risk assessment tools and concerns regarding bleeding risk may influence physicians’ clinical decisions. Educational initiatives and prospective studies may help improve guideline adherence. Full article

Background: Accurate prediction of bleeding events in patients receiving oral anticoagulants remains a key challenge in the management of atrial fibrillation (AF) and venous thromboembolism (VTE). Machine learning (ML) algorithms have emerged as powerful tools that capture complex, nonlinear interactions among risk factors, potentially offering superior accuracy. Objectives: To synthesize evidence comparing ML-based bleeding risk models with conventional clinical scores in anticoagulated AF and VTE populations. Methods: We conducted a systematic review with narrative synthesis of studies published between 2015 and 2025 applying ML algorithms to predict bleeding events in anticoagulated AF or VTE patients. Results: Thirteen studies were identified (seven AF and six VTE), including 464,523 participants in total. ML algorithms such as random forest (RF), extreme gradient boosting (XGBoost), and neural networks consistently outperformed traditional tools. In AF, AUCs ranged from 0.64 to 0.76 compared to 0.52–0.61 for HAS-BLED. In VTE, ML models achieved 0.59–0.91 versus 0.61–0.65 for RIETE or VTE-BLEED. Deep learning ensembles reached the highest AUCs (>0.8). Conclusions: ML-based bleeding risk models demonstrated statistically superior discrimination compared to established scores in both AF and VTE contexts, but effect sizes were modest (ΔAUC 0.05–0.15) and clinical utility remains uncertain. Broader validation, calibration assessment, and demonstration of impact on clinical outcomes are necessary before routine adoption. Full article

Pulmonary embolism (PE) is biologically heterogeneous. Despite guideline-directed anticoagulation, a subset of patients develops recurrent venous thromboembolism, persistent exertional limitation, residual perfusion defects, and progression to chronic thromboembolic pulmonary disease (CTEPD) or chronic thromboembolic pulmonary hypertension (CTEPH). Conventional risk factors explain much of the index event but incompletely account for thrombus non-resolution and chronic sequelae. Clonal hematopoiesis of indeterminate potential (CHIP)—the age-associated expansion of hematopoietic clones carrying somatic mutations—defines a measurable thrombo-inflammatory endophenotype that is strongly genotype- and clone-size (variant allele frequency; VAF)-dependent. Across human studies, JAK2-CHIP and TET2-CHIP show the most consistent associations with VTE/PE, whereas isolated DNMT3A-CHIP is frequently neutral, and larger clones tend to confer stronger effects. Mechanistically, CHIP can bias myeloid cells toward inflammasome/IL-1β signaling and endothelial activation, increase monocyte tissue factor activity, and promote immunothrombosis with neutrophil extracellular trap (NET) formation. NET-rich thrombi may adopt a dense fibrin–DNA–histone architecture that resists endogenous fibrinolysis, favoring organization and persistence. CTEPH offers a translational window to interrogate this model because thrombotic material and deep phenotyping are accessible. We synthesize genotype- and VAF-resolved clinical and mechanistic evidence using a structured strength-of-evidence framework and propose a pragmatic phenotyping roadmap with testable predictions for prospective post-PE validation. CHIP testing in PE/CTEPH remains investigational and should not currently change standard care. Full article

Psoriasis is a chronic, immune-mediated inflammatory skin disease requiring effective long-term systemic treatment. Current options, including using conventional small molecules and biological therapies, are limited by adverse events, suboptimal efficacy, or poor adherence due to inconvenient administration. This highlights an unmet need for safe, convenient, and effective oral self-administered dosage form therapies aligned with patient preferences. This review evaluates the mechanism, safety, and efficacy of next-generation tyrosine kinase 2 (TYK2) inhibitors and compares them to currently available therapeutic options. The pathogenesis of psoriasis is driven by chronic systemic inflammation mediated by the interleukin-23 (IL-23)/Th17/interleukin-17 (IL-17) axis. Selective TYK2 inhibitors, such as deucravacitinib, envudeucitinib, and zasocitinib, act through a unique allosteric mechanism by binding to the regulatory pseudokinase domain (JH2) rather than the enzyme’s catalytic domain. This enables highly selective suppression of IL-23-mediated inflammation while mitigating systemic toxicity seen with nonselective Janus kinase (JAK) inhibitors. Clinical trials (POETYK PSO-1 and PSO-2) and long-term extension studies demonstrate that deucravacitinib provides superior efficacy compared to the first-generation oral small molecule apremilast, with high and sustained response rates. It maintains durable efficacy for up to four years in patients with moderate to severe plaque psoriasis and shows a stable long-term safety profile, with low incidence of major adverse cardiovascular events (MACEs), venous thromboembolism (VTE), serious infections, and malignancies. Selective TYK2 inhibition bridges the therapeutic gap, providing an optimal balance of efficacy and oral convenience. With the potential to improve patient adherence and quality of life, these agents represent a promising option to become a first-line oral systemic therapy for psoriasis. Full article

Pancreatic cancer (PC) is a highly lethal malignancy linked to the highest rate of thromboembolic complications (TEC) among all solid tumors. TECs occur in approximately 5–40% of PC patients. The most common type of TEC in PC is venous thromboembolism (VTE). The mechanisms leading to frequent TEC in PC are complex and involve interactions between tumor-derived procoagulant factors and the prothrombotic tumor microenvironment (TME). Secretion of tissue factor and proinflammatory cytokines by tumor cells and the TME, overexpression of heparanase and podoplanin, impaired fibrynolysis and increased neutrophil extracellular trap formation lead to platelet hyperactivation resulting in hypercoagulability in PC. Understanding these mechanisms is crucial for identifying risk factors of TEC. Current thromboembolism risk models have limited predictive accuracy, which reduces their clinical usefulness. Identifying patients with thromboembolism is challenging because these events are often asymptomatic and their clinical presentation varies depending on the location of the thrombus. Treatment of VTE in PC depends on the phase of the VTE; in the acute phase, treatment primarily involves LMWH. For long-term management, LMWH may be replaced by direct oral anticoagulants such as apixaban, edoxaban, or rivaroxaban. In cases of VTE recurrence, increasing the LMWH dose, switching to an oral anticoagulant, or placing an inferior vena cava filter should be considered. LWMH and unfractionated heparin (UFH) are preferred options for VTE prophylaxis. Novel therapies, including factor XI inhibitors, show efficacy comparable to LMWH while offering a better safety profile. Full article

Background/Objectives: Venous thromboembolic disease (VTE) is the most common initial manifestation of antiphospholipid syndrome (APS). Determining which patients with VTE to test for APS can be a challenging clinical decision. We aimed to determine if patients with APS present with more significant venous thromboembolic clot burden, as compared to patients with VTE without a diagnosis of APS. Methods: A multi-hospital single-institution retrospective cohort study was designed. Patients with a diagnosis of VTE who had been tested for APS from 1 December 2019 to 31 January 2022 were included. Patients were stratified based on the presence of APS (APS versus non-APS). Significant venous thromboembolic clot burden was defined as PE involving the main and/or lobar pulmonary arteries or DVT involving the iliofemoral veins. Assessment of clot burden was performed by review of radiology reports of the index clotting event. Results: We included 748 patients with a history of VTE who had been tested for APS; 75 patients (10%) were positive for APS. Significant clot burden was present in 29 (38.7%) APS patients and 269 (40.0%) non-APS patients (OR 0.95, 95% CI 0.58–1.56; p = 0.85). No predictors for significant clot burden were found on multivariable analysis. Triple-positive APS (OR 0.83, 95% CI 0.16–4.21; p = 0.82) and primary APS (OR 0.72, 95% CI 0.15–3.45; p = 0.68) were not associated with more significant clot burden. Conclusions: This retrospective single-institution analysis suggests that patients with APS may not present with more significant venous thromboembolic clot burden than patients with VTE without APS. Full article

Cancer-associated thrombosis (CAT) is a major cause of morbidity and mortality in oncology, arising from complex interactions between tumor biology, host factors, and anticancer therapies. Growing evidence indicates that biological sex and gender-related factors modulate both thrombotic risk and clinical expression of venous thromboembolism (VTE) in patients with cancer. In this narrative review, we summarize current epidemiological, biological, and clinical data on sex- and gender-related differences in CAT across solid and hematologic malignancies. Men generally exhibit a higher overall incidence of VTE, whereas women may experience earlier, treatment-associated thrombotic events, with variability according to cancer type, stage, and therapy. Biological factors linked to coagulation and inflammation differ between sexes and may contribute to these patterns, although mechanistic evidence remains incomplete. Sex-related disparities also emerge in treatment-associated complications, including bleeding risk and abnormal uterine bleeding in anticoagulated women of reproductive age. In contrast, evidence for sex differences in oncohematology-associated thrombosis is limited and inconsistent. Gender-related inequalities in clinical trial participation further constrain the interpretation of available data. Overall, current evidence supports sex as a clinically relevant modifier of CAT risk, underscoring the need for systematic sex- and gender-informed research, to improve mechanistic understanding, and sex-stratified reporting to advance precision medicine in thrombosis and oncology. Full article

Inflammatory bowel disease is a recognized risk factor for venous thromboembolism, whereas arterial thrombotic events remain underappreciated despite their substantial clinical consequences. We report a 45-year-old man without significant comorbidities who developed severe ulcerative colitis complicated by diffuse arterial thrombosis, including cerebral infarctions, an ascending aortic mural thrombus, iliac artery thrombosis, and multi-organ infarctions. After stabilization with supportive care and anticoagulation, remission-directed ulcerative colitis therapy and a vascular safety–oriented maintenance strategy were initiated, including vedolizumab and individualized secondary thrombosis prevention. To contextualize this presentation, we integrate current evidence on the epidemiology, clinical phenotypes, underlying mechanisms, and risk factors for arterial thrombosis in inflammatory bowel disease, highlight disease activity as a dominant trigger, and summarize therapy-specific vascular safety considerations across IBD treatment classes. Full article