Editing Thrombosis

{{Short description|Formation of blood clots inside the blood vessels}}
{{for|the journal|Thrombosis (journal)}}
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{{Use British English|date=February 2024}}
{{Use mdy dates|date=February 2024}}
{{Infobox medical condition (new)
| name            = Thrombosis
| image           = Arterial thrombosis causing cyanosis.jpg
| caption         = [[Cyanosis]] of the lower right extremity, resulting from acute arterial thrombosis of the right leg (on the left side of the image)
| field           = [[Vascular surgery]], [[internal medicine]], [[pulmonology]]
| symptoms        = Dependent on location
| complications   =
| onset           =
| duration        =
| types           =
| causes          =
| risks           =
| diagnosis       =
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}}

'''Thrombosis''' ({{ety|grc|''θρόμβωσις'' (thrómbōsis)|clotting}}) is the formation of a [[Thrombus|blood clot]] inside a [[blood vessel]], obstructing the flow of [[blood]] through the [[circulatory system]]. When a blood vessel (a [[vein]] or an [[artery]]) is injured, the body uses [[platelets]] (thrombocytes) and [[fibrin]] to form a [[blood clot]] to prevent blood loss.  Even when a blood vessel is not injured, blood clots may form in the body under certain conditions. A clot, or a piece of the clot, that breaks free and begins to travel around the body is known as an [[embolus]].<ref>{{cite journal |vauthors=Furie B, Furie BC | title=Mechanisms of thrombus formation | journal=New England Journal of Medicine | year=2008 | volume=359 | pages=938–949 | doi=10.1056/NEJMra0801082 | pmid=18753650 | issue=9}}</ref><ref>{{cite book |author=Handin RI |veditors=Kasper DL, Braunwald E, Fauci AS |title=Harrison's Principles of Internal Medicine|edition=16th |year=2005 |publisher=McGraw-Hill |location=New York |isbn=978-0-07-139140-5 |chapter=Chapter 53: bleeding and thrombosis|display-editors=etal}}</ref>

Thrombosis may occur in veins ([[venous thrombosis]]) or in arteries ([[arterial thrombosis]]). Venous thrombosis (sometimes called DVT, [[deep vein thrombosis]]) leads to a blood clot in the affected part of the body, while arterial thrombosis (and, rarely, severe venous thrombosis) affects the blood supply and leads to damage of the tissue supplied by that artery ([[ischemia]] and [[necrosis]]). A piece of either an arterial or a venous thrombus can break off as an embolus, which could then travel through the circulation and lodge somewhere else as an [[embolism]]. This type of embolism is known as a [[thromboembolism]]. Complications can arise when a venous thromboembolism (commonly called a VTE) lodges in the lung as a [[pulmonary embolism]]. An arterial embolus may travel further down the affected blood vessel, where it can lodge as an embolism.{{citation needed|date=April 2022}}

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== Signs and symptoms ==
Thrombosis is generally defined by the type of blood vessel affected (arterial or venous thrombosis) and the precise location of the blood vessel or the organ supplied by it.{{citation needed|date=November 2021}}

=== Venous thrombosis ===
{{Main|Venous thrombosis}}<!--Structure of this section: limbs, then liver, then kidney, then head/brain-->

==== Deep vein thrombosis ====
{{Main|Deep vein thrombosis}}
Deep vein thrombosis (DVT) is the formation of a blood [[clot]] within a [[deep vein]]. It most commonly affects leg veins, such as the [[femoral vein]].{{cn|date=February 2025}}

Three factors are important in the formation of a blood clot within a deep vein—these are:{{cn|date=February 2025}}
* the rate of blood flow,
* the thickness of the blood and
* qualities of the vessel wall.

Classical signs of DVT include [[Swelling (medical)|swelling]], pain and redness of the affected area.<ref>{{Cite journal |last1=Min |first1=Seung-Kee |last2=Kim |first2=Young Hwan |last3=Joh |first3=Jin Hyun |last4=Kang |first4=Jin Mo |last5=Park |first5=Ui Jun |last6=Kim |first6=Hyung-Kee |last7=Chang |first7=Jeong-Hwan |last8=Park |first8=Sang Jun |last9=Kim |first9=Jang Yong |last10=Bae |first10=Jae Ik |last11=Choi |first11=Sun Young |last12=Kim |first12=Chang Won |last13=Park |first13=Sung Il |last14=Yim |first14=Nam Yeol |last15=Jeon |first15=Yong Sun |date=September 2016 |title=Diagnosis and Treatment of Lower Extremity Deep Vein Thrombosis: Korean Practice Guidelines |journal=Vascular Specialist International |volume=32 |issue=3 |pages=77–104 |doi=10.5758/vsi.2016.32.3.77 |issn=2288-7970 |pmc=5045251 |pmid=27699156}}</ref>

==== Paget-Schroetter disease ====
{{Main|Paget-Schroetter disease}}
[[Paget–Schroetter disease|Paget-Schroetter disease]] or upper extremity DVT (UEDVT) is the obstruction of an [[upper limb|arm]] vein (such as the [[axillary vein]] or [[subclavian vein]]) by a thrombus. The condition usually comes to light after vigorous exercise and usually presents in younger, otherwise healthy people. Men are affected more than women.<ref>{{Cite journal|title = Venous obstruction in the upper extremity; Paget-Schroetter's syndrome; a review of 320 cases|journal = Surgery, Gynecology & Obstetrics|date = February 1, 1949|issn = 0039-6087|pmid = 18108679|pages = 89–127|volume = 88|issue = 2|first = E. S. R.|last = Hughes}}</ref>

==== Budd-Chiari syndrome ====
{{Main|Budd-Chiari syndrome}}
[[Budd–Chiari syndrome|Budd-Chiari syndrome]] is the blockage of a [[hepatic vein]] or of the hepatic part of the [[inferior vena cava]]. This form of thrombosis presents with [[abdominal pain]], [[ascites]] and [[hepatomegaly|enlarged liver]]. Treatment varies between therapy and surgical intervention by the use of [[Shunt (medical)|shunts]].<ref>{{cite web |url= https://www.cancer.gov/publications/dictionaries/cancer-terms/def/shunt | title= shunt | website= National Cancer Institute |access-date= July 5, 2021}}</ref>

==== Portal vein thrombosis ====
{{Main|Portal vein thrombosis}}
Portal vein thrombosis affects the [[hepatic portal vein]], which can lead to portal [[hypertension]] and reduction of the blood supply to the [[liver]].<ref name="Webster">{{cite journal |last1=Webster |first1=GJM |last2=Burroughs |first2=AK |last3=Riordan |first3=SM |title=Review article: portal vein thrombosis&nbsp;– new insights into aetiology and management |journal=Alimentary Pharmacology & Therapeutics |volume=21 |issue=1 |pages=1–9 |date=January 2005 |url=http://www3.interscience.wiley.com/cgi-bin/fulltext/118696389/HTMLSTART |archive-url=https://archive.today/20121210090509/http://www3.interscience.wiley.com/cgi-bin/fulltext/118696389/HTMLSTART |url-status=dead |archive-date=December 10, 2012 |pmid=15644039 |doi=10.1111/j.1365-2036.2004.02301.x |citeseerx=10.1.1.536.2660 |s2cid=5673778 }}</ref> It usually happens in the setting of another disease such as [[pancreatitis]], [[cirrhosis]], [[diverticulitis]] or [[cholangiocarcinoma]].<ref>{{Cite journal |last1=DeLeve |first1=LD |last2=Valla |first2=DC |last3=Garcia-Tsao |first3=G |date=2009 |title=Vascular disorders of the liver |journal=Hepatology |volume=49 |issue=5 |pages=1729–64 |doi=10.1002/hep.22772 |pmid=19399912 |pmc=6697263}}</ref>

==== Renal vein thrombosis ====
{{Main|Renal vein thrombosis}}
Renal vein thrombosis is the obstruction of the [[renal vein]] by a thrombus. This tends to lead to reduced drainage from the [[kidney]].<ref>{{cite web |title=Renal vein thrombosis: MedlinePlus Medical Encyclopedia |url=https://medlineplus.gov/ency/article/000513.htm |website=medlineplus.gov |access-date=May 27, 2019 |language=en}}</ref>

==== Cerebral venous sinus thrombosis ====
{{Main|Cerebral venous sinus thrombosis}}
Cerebral venous sinus thrombosis (CVST) is a rare form of [[stroke]] which results from the blockage of the [[dural venous sinuses]] by a thrombus. Symptoms may include headache, abnormal vision, any of the symptoms of stroke such as weakness of the face and limbs on one side of the body and [[seizures]]. The diagnosis is usually made with a [[Computed Tomography|CT]] or [[Magnetic Resonance Imaging|MRI scan]]. The majority of persons affected make a full recovery. The [[mortality rate]] is 4.3%.<ref name="Canhao">{{cite journal | last1=Canhão | first1=P |author2=Ferro JM, Lindgren AG| title=Causes and predictors of death in cerebral venous thrombosis | volume=36 | issue=8 | pages=1720–1725 | journal=Stroke | date=August 2005 | pmid=16002765 | doi=10.1161/01.STR.0000173152.84438.1c|display-authors=etal| doi-access=free }}</ref>

==== Jugular vein thrombosis ====
[[Jugular vein]] thrombosis is a condition that may occur due to infection, intravenous drug use or malignancy. Jugular vein thrombosis can have a varying list of complications, including: [[sepsis|systemic sepsis]], [[pulmonary embolism]], and [[papilledema]]. Though characterized by a sharp pain at the site of the vein, it can prove difficult to diagnose, because it can occur at random.<ref>{{Cite web|url=http://www.emedicine.com/med/topic2762c.htm|title=eMedicine Article on Internal Jugular Vein Thrombosis by Dale K. Mueller|access-date=December 8, 2015|archive-date=April 14, 2021|archive-url=https://web.archive.org/web/20210414072654/http://www.emedicine.com/med/topic2762c.htm|url-status=dead}}</ref>

==== Cavernous sinus thrombosis ====
{{Main|Cavernous sinus thrombosis}}
[[Cavernous sinus thrombosis]] is a specialised form of cerebral venous sinus thrombosis, where there is thrombosis of the [[cavernous sinus]] of the basal skull dura, due to the retrograde spread of infection and endothelial damage from the [[danger triangle]] of the face. The facial veins in this area anastomose with the [[superior ophthalmic vein|superior]] and [[inferior ophthalmic vein|inferior]] ophthalmic veins of the orbit, which drain directly posteriorly into the cavernous sinus through the [[superior orbital fissure]]. [[Staphylococcus aureus|Staphyloccoal]] or [[Streptococcal]] infections of the face, for example nasal or upper lip pustules may thus spread directly into the cavernous sinus, causing stroke-like symptoms of [[double vision]], [[strabismus|squint]], as well as spread of infection to cause [[meningitis]].<ref>{{Cite web|url=https://www.sun.ac.za/english/faculty/healthsciences/surgical-sciences/Documents/Specialist%20Guidelines/Cavernous%20sinus%20thrombosis.pdf|title=Guidelines Cavernous sinus thrombosis}}</ref>

=== Arterial thrombosis ===

Arterial thrombosis is the formation of a thrombus within an [[artery]]. In most cases, arterial thrombosis follows rupture of [[atheroma]] (a fat-rich deposit in the blood vessel wall), and is therefore referred to as ''atherothrombosis''. [[Arterial embolism]] occurs when clots then migrate downstream and can affect any organ.<ref>[http://www.mdguidelines.com/arterial-embolism-and-thrombosis MDGuidelines > Arterial Embolism And Thrombosis] {{Webarchive|url=https://web.archive.org/web/20180202063012/http://www.mdguidelines.com/arterial-embolism-and-thrombosis |date=February 2, 2018 }} From ''The Medical Disability Advisor'' by Presley Reed, MD. Retrieved on April 30, 2010</ref> Alternatively, arterial occlusion occurs as a consequence of embolism of blood clots originating from the heart ("cardiogenic" emboli). The most common cause is [[atrial fibrillation]], which causes a blood stasis within the atria with easy thrombus formation, but blood clots can develop inside the heart for other reasons too as infective endocarditis.{{citation needed|date=July 2021}}

==== Stroke ====
{{Main|Stroke}}
[[File:ThrombusRtMCAM1Mark.png|thumb|Acute thrombus in the right MCA M1 branch]]
A stroke is the rapid decline of brain function due to a disturbance in the supply of blood to the brain.<ref name="men">{{cite journal | last1=Mendelson | first1=Scott J. | last2=Prabhakaran | first2=Shyam | title=Diagnosis and Management of Transient Ischemic Attack and Acute Ischemic Stroke | journal=JAMA | volume=325 | issue=11 | date=March 16, 2021 | pages=1088–1098 | issn=0098-7484 | pmid=33724327 | doi=10.1001/jama.2020.26867 | s2cid=232242365 }}</ref> This can be due to [[ischemia]], thrombus, [[embolus]] (a lodged particle) or [[hemorrhage]] (a bleed).<ref name=men/>

In thrombotic stroke, a thrombus (blood clot) usually forms around [[atherosclerotic]] plaques. Since blockage of the artery is gradual, the onset of symptomatic thrombotic strokes is slower. Thrombotic stroke can be divided into two categories — large vessel disease or small vessel disease. The former affects vessels such as the [[internal carotid]]s, [[Vertebral artery|vertebral]] and the [[circle of Willis]]. The latter can affect smaller vessels, such as the branches of the circle of Willis.{{citation needed|date=November 2021}}

==== Myocardial infarction ====
{{Main|Myocardial infarction}}
Myocardial infarction (MI), or heart attack, is caused by ischemia (restriction in the blood supply), which is often due to the obstruction of a [[coronary artery]] by a thrombus. This restriction gives an insufficient supply of oxygen to the heart muscle which then results in tissue death (infarction). A lesion is then formed which is the [[infarct]]. MI can quickly become fatal if emergency medical treatment is not received promptly. If diagnosed within 12 hours of the initial episode (attack) then [[thrombolysis|thrombolytic therapy]] is initiated.{{citation needed|date=November 2021}}

===Limb ischemia===
An arterial thrombus or embolus can also form in the limbs, which can lead to [[acute limb ischemia]].<ref>{{cite journal|last1=Creager|first1=Mark A.|last2=Kaufman|first2=John A.|last3=Conte|first3=Michael S.|title=Acute Limb Ischemia|journal=New England Journal of Medicine|date=June 7, 2012|volume=366|issue=23|pages=2198–2206|doi=10.1056/NEJMcp1006054|pmid=22670905}}{{subscription required}}</ref>

==== Other sites ====
[[Hepatic artery thrombosis]] usually occurs as a devastating complication after [[liver transplantation]].<ref>{{cite journal|last1=Bekker|first1=J.|last2=Ploem|first2=S.|last3=de Jong|first3=K. P.|title=Early Hepatic Artery Thrombosis after Liver Transplantation: A Systematic Review of the Incidence, Outcome and Risk Factors|journal=American Journal of Transplantation|date=April 2009|volume=9|issue=4|pages=746–757|doi=10.1111/j.1600-6143.2008.02541.x|pmid=19298450|doi-access=free}}</ref>

==Causes==
Thrombosis prevention is initiated with assessing the risk for its development. [[ThroLy score|Some people have a higher risk]] of developing thrombosis and its possible development into [[thromboembolism]].{{sfn|Hoffman|2012|page=960}} Some of these risk factors are related to [[inflammation]].

"[[Virchow's triad]]" has been suggested to describe the three factors necessary for the formation of thrombosis:
* [[Hemodynamic|hemodynamic changes]] (blood stasis or turbulence),
* vessel wall ([[endothelial]]) injury/dysfunction, and
* altered blood coagulation ([[hypercoagulability]]).{{sfn|Moliterno|2013|page=306}}{{sfn|Brunner|2010|page=874}}

Some risk factors predispose for venous thrombosis while others increase the risk of arterial thrombosis.{{citation needed|date=December 2016}} Newborn babies in the neonatal period are also at risk of a thromboembolism.<ref name=":1">{{Cite journal|last1=Romantsik|first1=Olga|last2=Bruschettini|first2=Matteo|last3=Zappettini|first3=Simona|last4=Ramenghi|first4=Luca Antonio|last5=Calevo|first5=Maria Grazia|date=November 7, 2016|title=Heparin for the treatment of thrombosis in neonates|url=|journal=The Cochrane Database of Systematic Reviews|volume=2016|issue=11 |pages=CD012185|doi=10.1002/14651858.CD012185.pub2|issn=1469-493X|pmc=6464761|pmid=27820879}}</ref>

{| class="wikitable sortable collapsible"
|+ Risk factors for thrombosis
! Factor !! Notes !! References
|-
| Previous episodes of thrombosis||  ||{{sfn|Moliterno|2013|page=306}}
|-
| [[Vasoconstriction]] ||  ||{{sfn|Copstead|2013|page=320}}
|-
| Slow or turbulent blood flow ||  slow flow is modifiable with exercise ||{{sfn|Copstead|2013|page=320}}
|-
| Stroke ||  ||{{sfn|Moliterno|2013|page=307}}
|-
| Heart failure ||  ||{{sfn|Moliterno|2013|page=307}}
|-
| Sedentary life style || modifiable  ||{{sfn|Copstead|2013|page=320}}
|-
| Plaster cast || transient ||{{sfn|Moliterno|2013|page=307}}
|-
|[[Dehydration]] || modifiable ||{{sfn|Copstead|2013|page=320}}
|-
| Acute respiratory failure ||  ||{{sfn|Moliterno|2013|page=307}}
|-
| [[Cardiac dysrhythmia|Dysrhythmia]]s ||  ||{{sfn|Copstead|2013|page=320}}
|-
| [[Shock (circulatory)|Shock]] ||  ||{{sfn|Copstead|2013|page=320}}
|-
| [[Obesity]]|| modifiable ||{{sfn|Hoffman|2012|page=960}}{{sfn|Moliterno|2013|page=307}}{{sfn|Abele|2014|page=}}{{sfn|Brunner|2010|page=875}}{{sfn|Copstead|2013|page=329}}
|-
| Pregnancy and the post-partum period  ||   ||{{sfn|Hoffman|2012|page=960}}{{sfn|Brunner|2010|page=875}}{{sfn|Copstead|2013|page=329}}
|-
| [[Varicose veins]] ||  ||{{sfn|Moliterno|2013|page=307}}{{sfn|Brunner|2010|page=875}}
|-
| Surgery  ||   ||{{sfn|Hoffman|2012|page=960}}{{sfn|Brunner|2010|page=875}}
|-
| [[Major trauma|Trauma]]  ||   ||{{sfn|Hoffman|2012|page=960}}{{sfn|Moliterno|2013|page=307}}{{sfn|Brunner|2010|page=875}}
|-
| Estrogen-based [[oral contraceptive]]   || discontinuation reduces risk  ||{{sfn|Hoffman|2012|page=960}}{{sfn|Copstead|2013|page=320}}{{sfn|Brunner|2010|page=875}}
|-
|[[Hormone replacement therapy]]   || discontinuation reduces risk ||{{sfn|Hoffman|2012|page=960}}
|-
| Ovarian hyper-stimulation therapy to treat infertility   ||   ||{{sfn|Hoffman|2012|page=960}}
|-
| Compression of a vein or [[artery]] by abnormality, tumor, hematoma  ||   ||{{sfn|Hoffman|2012|page=960}}
|-
| Long surgeries  ||   ||{{sfn|Abele|2014|page=}}
|-
| [[Transvenous pacing|Pacing wires]]  ||   ||{{sfn|Brunner|2010|page=875}}<ref>{{cite web | title = Pacing wire | publisher= The Free Dictionary| url = http://medical-dictionary.thefreedictionary.com/pacing+wire | access-date = December 18, 2016  }}</ref>
|-
| Local vein damage, incompetent valves ||   ||{{sfn|Copstead|2013|page=320}}{{sfn|Brunner|2010|page=875}}{{sfn|Copstead|2013|page=329}}
|-
| [[Central venous catheter]]s ||   ||{{sfn|Brunner|2010|page=875}}
|-
| [[Kidney dialysis|Dialysis]] [[catheter]]s   ||   ||{{sfn|Brunner|2010|page=875}}
|-
| [[Repetitive motion injury]]   ||   ||{{sfn|Brunner|2010|page=875}}
|-
| Immobility  || modifiable risk ||{{sfn|Moliterno|2013|page=307}}{{sfn|Brunner|2010|page=875}}
|-
| [[Spinal cord injury]]  ||   ||{{sfn|Brunner|2010|page=875}}
|-
| Age ||   ||{{sfn|Hoffman|2012|page=960}}{{sfn|Copstead|2013|page=320}}{{sfn|Moliterno|2013|page=307}}{{sfn|Brunner|2010|page=875}}
|-
| [[Cancer]]s  ||   ||{{sfn|Brunner|2010|page=875}}
|-
| [[Sepsis]]  ||   ||{{sfn|Brunner|2010|page=875}}
|-
| [[Polycythemia]]   ||   ||{{sfn|Brunner|2010|page=875}}
|-
| [[Protein C]] and/or [[Protein S|S]] deficiency  ||  congenital; associated with [[Warfarin necrosis]] ||{{sfn|Brunner|2010|page=875}}
|-
|[[Antiphospholipid syndrome|Antiphospholipid antibody syndrome]]   ||  altered coagulation ||{{sfn|Brunner|2010|page=875}}
|-
| [[Factor V Leiden]] defect   || altered coagulation  ||{{sfn|Brunner|2010|page=875}}
|-
| [[Prothrombin G20210A]] defect   || altered coagulation  ||{{sfn|Brunner|2010|page=875}}
|-
| Elevated [[PAI-1]]  || inhibits physiological breakdown of [[thrombus|blood clots]]  ||  <ref name="pmid16102055">{{cite journal | vauthors = Vaughan DE | title = PAI-1 and atherothrombosis | journal = Journal of Thrombosis and Haemostasis | volume = 3 | issue = 8 | pages = 1879–83 | date = August 2005 | pmid = 16102055 | doi = 10.1111/j.1538-7836.2005.01420.x | s2cid = 6651339 | doi-access =  }}</ref>
|-
| [[Hyperhomocysteinemia]]  || altered coagulation  ||{{sfn|Brunner|2010|page=875}}
|-
| Elevated [[thrombin|factors II]], [[Factor VIII|VIII]], [[Factor IX|IX]], [[Factor XI|XI]]  || altered coagulation  ||{{sfn|Brunner|2010|page=875}}
|-
| [[Antithrombin III deficiency]]  || altered coagulation  ||{{sfn|Brunner|2010|page=875}}
|-
| Falls and hip fracture  || related to immobility   ||{{sfn|Brunner|2010|page=876}}
|-
| Selective estrogen-receptor modulators  ||   ||{{sfn|Hoffman|2012|page=960}}
|-
| [[Erythropoiesis]]-stimulating agents  ||   ||{{sfn|Hoffman|2012|page=960}}
|-
| Acute medical illness   ||   ||{{sfn|Hoffman|2012|page=960}}
|-
| [[Inflammatory bowel disease]]   ||   ||{{sfn|Hoffman|2012|page=960}}
|-
| Nephrotic syndrome   ||   ||{{sfn|Hoffman|2012|page=960}}
|-
|Myeloproliferative disorders   ||   ||{{sfn|Hoffman|2012|page=960}}
|-
|Paroxysmal nocturnal hemoglobinnuria   ||   ||{{sfn|Hoffman|2012|page=960}}
|-
| [[Thrombophilia]]s  ||   ||{{sfn|Hoffman|2012|page=960}}
|-
| Post-menopausal hormone replacement therapy  || discontinuation reduces risk   ||{{sfn|Hoffman|2012|page=960}}
|-
| Right heart failure   ||   ||{{sfn|Copstead|2013|page=329}}
|-
| Venous inflammation/phlebitis || when a thrombus forms, it is [[thrombophlebitis]] ||{{sfn|Copstead|2013|page=320}}
|-
|Ambient air pollution
|thought to be related to inflammation
|<ref>{{Cite journal|last1=Ho|first1=Andrew F. W.|last2=Zheng|first2=Huili|last3=De Silva|first3=Deidre A.|last4=Wah|first4=Win|last5=Earnest|first5=Arul|last6=Pang|first6=Yee H.|last7=Xie|first7=Zhenjia|last8=Pek|first8=Pin P.|last9=Liu|first9=Nan|date=November 2018|title=The Relationship Between Ambient Air Pollution and Acute Ischemic Stroke: A Time-Stratified Case-Crossover Study in a City-State With Seasonal Exposure to the Southeast Asian Haze Problem|journal=Annals of Emergency Medicine|volume=72|issue=5|pages=591–601|doi=10.1016/j.annemergmed.2018.06.037|issn=1097-6760|pmid=30172448|s2cid=52144033}}</ref><ref>{{Cite journal|last1=Ho|first1=Andrew Fu Wah|last2=Zheng|first2=Huili|last3=Earnest|first3=Arul|last4=Cheong|first4=Kang Hao|last5=Pek|first5=Pin Pin|last6=Seok|first6=Jeon Young|last7=Liu|first7=Nan|last8=Kwan|first8=Yu Heng|last9=Tan|first9=Jack Wei Chieh|date=March 19, 2019|title=Time-Stratified Case Crossover Study of the Association of Outdoor Ambient Air Pollution With the Risk of Acute Myocardial Infarction in the Context of Seasonal Exposure to the Southeast Asian Haze Problem|journal=Journal of the American Heart Association|volume=8|issue=6|pages=e011272|doi=10.1161/JAHA.118.011272|pmid=31112443|issn=2047-9980|pmc=6475051}}</ref><ref>{{Cite journal|last1=Ho|first1=Andrew Fu Wah|last2=Wah|first2=Win|last3=Earnest|first3=Arul|last4=Ng|first4=Yih Yng|last5=Xie|first5=Zhenjia|last6=Shahidah|first6=Nur|last7=Yap|first7=Susan|last8=Pek|first8=Pin Pin|last9=Liu|first9=Nan|date=November 15, 2018|title=Health impacts of the Southeast Asian haze problem – A time-stratified case crossover study of the relationship between ambient air pollution and sudden cardiac deaths in Singapore|journal=International Journal of Cardiology|volume=271|pages=352–358|doi=10.1016/j.ijcard.2018.04.070|issn=1874-1754|pmid=30223374|s2cid=52282745 }}</ref>
|}

== Mechanism ==
=== Pathogenesis ===
{{Main|Virchow's triad}}The main causes of thrombosis are given in [[Virchow's triad]] which lists [[thrombophilia]], [[endothelial cell]] injury, and disturbed [[blood flow]]. Generally speaking the risk for thrombosis increases over the life course of individuals, depending on life style factors like smoking, diet, and physical activity, the presence of other diseases like cancer or autoimmune disease, while also platelet properties change in aging individuals which is an important consideration as well.<ref>{{cite journal|last1=Faria|first1=Alessandra V.S. |last2= Andrade|first2=Sheila S|last3=Peppelenbosch|first3=Maikel P.|last4=Ferreira-Halder| first4=Carmen V.|last5=Fuhler|first5=Gwenny M.|title=Platelets in aging and cancer-"double-edged sword"| journal=Cancer and Metastasis Reviews |date=December 2020|volume=39|issue=4|pages=1205–1221|doi=10.1007/s10555-020-09926-2|pmid=32869161|pmc=458881| doi-access=free}}</ref>

==== Hypercoagulability ====
{{Main|Thrombophilia}}
Hypercoagulability or ''thrombophilia'', is caused by, for example, [[genetic disorder|genetic deficiencies]] or [[autoimmune disease|autoimmune disorder]]s. Recent studies indicate that white blood cells play a pivotal role in deep vein thrombosis, mediating numerous pro-thrombotic actions.<ref>{{cite journal|last1=Swystun|first1=L. L.|last2=Liaw|first2=P. C.|title=The role of leukocytes in thrombosis|journal=Blood|date=June 27, 2016|volume=128|issue=6|pages=753–762|doi=10.1182/blood-2016-05-718114|pmid=27354721|doi-access=free}}</ref>

==== Endothelial cell injury ====
Any inflammatory process, such as trauma, surgery or infection, can cause damage to the [[endothelium|endothelial lining]] of the vessel's wall. The main mechanism is exposure of [[tissue factor]] to the blood coagulation system.<ref name="labtestsonline">[http://www.labtestsonline.org/understanding/conditions/hypercoagulable_disorders-3.html labtestsonline > Hypercoagulable Disorders] {{Webarchive|url=https://web.archive.org/web/20070618165003/http://www.labtestsonline.org/understanding/conditions/hypercoagulable_disorders-3.html |date=June 18, 2007 }} This article was last reviewed on May 23, 2007, and was last modified on March 6, 2010.</ref> Inflammatory and other stimuli (such as [[hypercholesterolemia]]) can lead to changes in [[gene expression]] in endothelium producing to a pro-thrombotic state.<ref name=":0" /> When this occurs, endothelial cells [[Downregulation and upregulation|downregulate]] substances such as [[thrombomodulin]], which is a key modulator of thrombin activity.<ref>{{Cite journal|last1=Ito|first1=Takashi|last2=Kakihana|first2=Yasuyuki|last3=Maruyama|first3=Ikuro|date=January 1, 2016|title=Thrombomodulin as an intravascular safeguard against inflammatory and thrombotic diseases|journal=Expert Opinion on Therapeutic Targets|volume=20|issue=2|pages=151–158|doi=10.1517/14728222.2016.1086750|issn=1744-7631|pmid=26558419|s2cid=207486815}}</ref> The result is a sustained activation of thrombin and reduced production of [[protein C]] and tissue factor inhibitor, which furthers the pro-thrombotic state.<ref name=":0" />

Endothelial injury is almost invariably involved in the formation of thrombi in arteries, as high rates of blood flow normally hinder clot formation. In addition, arterial and cardiac clots are normally rich in platelets–which are required for clot formation in areas under high stress due to blood flow.<ref name=":0">{{Cite book|title=Robbins and Cotran Pathologic Basis of Disease|last=Kumar|first=Vinay|publisher=Elsevier|year=2015|isbn=978-1-4557-2613-4|location=Philadelphia|pages=122–130}}</ref>

==== Disturbed blood flow ====
{{Further|Blood flow}}
[[File:Potential Mechanisms of Cancer-Related Hypercoagulability.png|thumb|Cancer-associated thrombosis can result from: (1) stasis, i.e., direct pressure on blood vessels by the tumor mass, poor performance status, and bed rest following surgical procedures; (2) iatrogenic, due to treatment with antineoplastic medications; and (3) secretion of heparanase from malignant tumors that results in degradation of endogenous heparin.<ref>{{Cite journal|last1=Nasser|first1=Nicola J.|last2=Fox|first2=Jana|last3=Agbarya|first3=Abed|date=March 2020|title=Potential Mechanisms of Cancer-Related Hypercoagulability|journal=Cancers|language=en|volume=12|issue=3|pages=566|doi=10.3390/cancers12030566|pmc=7139427|pmid=32121387|doi-access=free}}</ref>]]
Causes of disturbed blood flow include stagnation of blood flow past the point of injury, or [[venous stasis]] which may occur in heart failure,<ref name=labtestsonline /> or after long periods of sedentary behaviour, such as sitting on a long airplane flight. Also, [[atrial fibrillation]], causes stagnant blood in the left atrium (LA), or [[left atrial appendage]] (LAA), and can lead to a [[thromboembolism]].<ref name=labtestsonline /> [[Cancers]] or [[malignancies]] such as [[leukemia]] may cause increased risk of thrombosis by possible activation of the coagulation system by cancer cells or secretion of procoagulant substances ([[paraneoplastic syndrome]]), by external compression on a blood vessel when a solid tumor is present, or (more rarely) extension into the vasculature (for example, renal cell cancers extending into the renal veins).<ref name=labtestsonline /> Also, treatments for cancer (radiation, chemotherapy) often cause additional hypercoagulability.<ref name=labtestsonline /> There are scores that correlate different aspects of patient data (comorbidities, vital signs, and others) to risk of thrombosis, such as the POMPE-C, which stratifies risk of mortality due to pulmonary embolism in patients with cancer, who typically have higher rates of thrombosis.<ref>{{cite journal|last1=van der Hulle|first1=T|last2=den Exter|first2=PL|last3=Kooiman|first3=J|last4=van der Hoeven|first4=JJ|last5=Huisman|first5=MV|last6=Klok|first6=FA|title=Meta-analysis of the efficacy and safety of new oral anticoagulants in patients with cancer-associated acute venous thromboembolism.|journal=J Thromb Haemost|date=2014|volume=12|issue=7|pages=1116–20|pmid=24819040|doi=10.1111/jth.12605|s2cid=19395326}}</ref> Also, there are several predictive scores for thromboembolic events, such as Padua,<ref>{{Cite journal|last1=BARBAR|first1=S.|last2=NOVENTA|first2=F.|last3=ROSSETTO|first3=V.|last4=FERRARI|first4=A.|last5=BRANDOLIN|first5=B.|last6=PERLATI|first6=M.|last7=DE BON|first7=E.|last8=TORMENE|first8=D.|last9=PAGNAN|first9=A.|last10=PRANDONI|first10=P.|date=November 2010|title=A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score|journal=Journal of Thrombosis and Haemostasis|volume=8|issue=11|pages=2450–2457|doi=10.1111/j.1538-7836.2010.04044.x|pmid=20738765|issn=1538-7933|doi-access=free}}</ref> Khorana,<ref>{{Cite journal|last1=Khorana|first1=Alok A.|last2=Francis|first2=Charles W.|last3=Culakova|first3=Eva|last4=Fisher|first4=Richard I.|last5=Kuderer|first5=Nicole M.|last6=Lyman|first6=Gary H.|date=January 20, 2006|title=Thromboembolism in Hospitalized Neutropenic Cancer Patients|journal=Journal of Clinical Oncology|volume=24|issue=3|pages=484–490|doi=10.1200/jco.2005.03.8877|pmid=16421425|issn=0732-183X|doi-access=free}}</ref><ref>{{Cite journal|last1=Khorana|first1=Alok A.|last2=Kuderer|first2=Nicole M.|last3=Culakova|first3=Eva|last4=Lyman|first4=Gary H.|last5=Francis|first5=Charles W.|date=May 15, 2008|title=Development and validation of a predictive model for chemotherapy-associated thrombosis|journal=Blood|volume=111|issue=10|pages=4902–4907|doi=10.1182/blood-2007-10-116327|pmid=18216292|pmc=2384124|issn=0006-4971|doi-access=free}}</ref> and [[ThroLy score]].<ref>{{Cite journal|last1=Antic|first1=Darko|last2=Milic|first2=Natasa|last3=Nikolovski|first3=Srdjan|last4=Todorovic|first4=Milena|last5=Bila|first5=Jelena|last6=Djurdjevic|first6=Predrag|last7=Andjelic|first7=Bosko|last8=Djurasinovic|first8=Vladislava|last9=Sretenovic|first9=Aleksandra|last10=Vukovic|first10=Vojin|last11=Jelicic|first11=Jelena|date=July 22, 2016|title=Development and validation of multivariable predictive model for thromboembolic events in lymphoma patients|journal=American Journal of Hematology|volume=91|issue=10|pages=1014–1019|doi=10.1002/ajh.24466|pmid=27380861|s2cid=1724916|issn=0361-8609|doi-access=free}}</ref>

=== Pathophysiology ===

==== Natural history ====
[[Fibrinolysis]] is the physiological breakdown of blood clots by enzymes such as [[plasmin]].{{cn|date=February 2025}}

Organisation: following the thrombotic event, residual vascular thrombus will be re-organised histologically with several possible outcomes. For an occlusive thrombus (defined as thrombosis within a small vessel that leads to complete occlusion), [[wound healing]] will reorganise the occlusive thrombus into collagenous [[scar]] tissue, where the scar tissue will either permanently obstruct the vessel, or contract down with [[myofibroblast]]ic activity to unblock the [[lumen (anatomy)|lumen]]. For a mural thrombus (defined as a thrombus in a large vessel that restricts the blood flow but does not occlude completely), histological reorganisation of the thrombus does not occur via the classic [[wound healing]] mechanism. Instead, the [[platelet-derived growth factor]] degranulated by the clotted [[platelet]]s will attract a layer of [[smooth muscle]] cells to cover the clot, and this layer of mural smooth muscle will be vascularised by the blood inside the vessel lumen rather than by the [[vasa vasorum]].{{citation needed|date=November 2021}}

Ischemia/infarction: if an arterial thrombus cannot be lysed by the body and it does not embolise, and if the thrombus is large enough to impair or occlude blood flow in the involved artery, then local [[ischemia]] or [[infarction]] will result. A [[venous thrombosis|venous thrombus]] may or may not be ischemic, since veins distribute deoxygenated blood that is less vital for cellular metabolism. Nevertheless, non-ischemic venous thrombosis may still be problematic, due to the swelling caused by blockage to venous drainage. In [[deep vein thrombosis]] this manifests as pain, redness, and swelling; in [[retinal vein occlusion]] this may result in [[macular oedema]] and [[visual acuity]] impairment, which if severe enough can lead to blindness.{{cn|date=February 2025}}

==== Embolization ====
{{Further|Embolus}}
A thrombus may become detached and enter circulation as an [[Embolism|embolus]], finally lodging in and completely obstructing a blood vessel, which unless treated very quickly will lead to tissue necrosis (an [[infarction]]) in the area past the occlusion. Venous thrombosis can lead to pulmonary embolism when the migrated embolus becomes lodged in the lung. In people with a "shunt" (a connection between the pulmonary and systemic circulation), either in the heart or in the lung, a venous clot can also end up in the arteries and cause arterial embolism.{{citation needed|date=December 2016}}

Arterial embolism can lead to obstruction of blood flow through the blood vessel that is obstructed by it, and a lack of oxygen and nutrients ([[ischemia]]) of the downstream tissue. The tissue can become irreversibly damaged, a process known as [[necrosis]]. This can affect any organ; for instance, arterial embolism of the brain is one of the causes of stroke.{{citation needed|date=December 2016}}

== Prevention ==
{{Main|Thrombosis prevention}}
The use of [[heparin]] following surgery is common if there are no issues with bleeding. Generally, a risk-benefit analysis is required, as all anticoagulants lead to an increased risk of bleeding.<ref>{{NICE|92|Venous thromboembolism: reducing the risk for patients in hospital|January 2010}}</ref> In people admitted to hospital, thrombosis is a major cause for complications and occasionally death. In the UK, for instance, the Parliamentary [[Health Select Committee]] heard in 2005 that the annual rate of death due to thrombosis was 25,000, with at least 50% of these being hospital-acquired.<ref name="Hunt">{{cite journal |author=Hunt BJ |title=Awareness and politics of venous thromboembolism in the United kingdom |journal=Arterioscler. Thromb. Vasc. Biol. |volume=28 |issue=3 |pages=398–9 |date=March 2008 |pmid=18296598 |doi=10.1161/ATVBAHA.108.162586 |doi-access=free }}</ref> Hence ''thromboprophylaxis'' (prevention of thrombosis) is increasingly emphasized. In patients admitted for surgery, graded [[compression stockings]] are widely used, and in severe illness, prolonged immobility and in all [[orthopedic surgery]], [[clinical practice guideline|professional guidelines]] recommend [[low molecular weight heparin]] (LMWH) administration, mechanical calf compression or (if all else is contraindicated and the patient has recently developed deep vein thrombosis) the insertion of a [[Inferior vena cava filter|vena cava filter]].<ref>{{NICE|46|Venous thromboembolism (surgical)|April 2007}}</ref><ref name="ACCP">{{cite journal |vauthors=Geerts WH, Pineo GF, Heit JA, etal |title=Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy |journal=Chest |volume=126 |issue=3 Suppl |pages=338S–400S |date=September 2004 |pmid=15383478 |doi=10.1378/chest.126.3_suppl.338S |url=http://www.chestjournal.org/cgi/content/full/126/3_suppl/338S |archive-url=https://archive.today/20041011003734/http://www.chestjournal.org/cgi/content/full/126/3_suppl/338S |url-status = dead|archive-date=October 11, 2004 }}</ref> In patients with medical rather than surgical illness, LMWH too is known to prevent thrombosis,<ref name=ACCP /><ref>{{cite journal |vauthors=Dentali F, Douketis JD, Gianni M, Lim W, Crowther MA |title=Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients |journal=Ann. Intern. Med. |volume=146 |issue=4 |pages=278–88 |date=February 2007 |pmid=17310052 |doi=10.7326/0003-4819-146-4-200702200-00007|citeseerx=10.1.1.694.4563 |s2cid=27605124 }}</ref> and in the United Kingdom the [[Chief Medical Officer (United Kingdom)|Chief Medical Officer]] has issued guidance to the effect that preventative measures should be used in medical patients, in anticipation of formal guidelines.<ref name=Hunt />

== Treatment ==
The treatment for thrombosis depends on whether it is in a vein or an artery, the impact on the person, and the risk of complications from treatment.{{citation needed|date=July 2024}}

===Anticoagulation===
{{main|Anticoagulant}}
[[Warfarin]] and [[vitamin K antagonists]] are [[anticoagulant]]s that can be taken orally to reduce thromboembolic occurrence. Where a more effective response is required, heparin can be given (by injection) concomitantly. As a side effect of any anticoagulant, the risk of bleeding is increased, so the [[international normalized ratio]] of blood is monitored. Self-monitoring and self-management are safe options for competent patients, though their practice varies. In Germany, about 20% of patients were self-managed while only 1% of U.S. patients did home self-testing (according to one 2012 study).<ref name="Heneghan">{{cite journal |vauthors=Heneghan C, Ward A, Perera R |year=2012 |title=Self-monitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data |journal=The Lancet |volume=379 |issue=9813 |pages=322–334 |doi=10.1016/S0140-6736(11)61294-4 |pmid= 22137798|url=http://discovery.ucl.ac.uk/1468252/1/Gardiner_28.%20Heneghan%20Lancet%202011.pdf |doi-access=free}}</ref> Other medications such as [[direct thrombin inhibitor]]s and [[direct Xa inhibitor]]s are increasingly being used instead of warfarin.{{citation needed|date=December 2016}}

===Thrombolysis===
[[Thrombolysis]] is the pharmacological destruction of blood clots by administering [[thrombolytic drug]]s including [[tissue plasminogen activator|recombinant tissue plasminogen activator]], which enhances the normal destruction of blood clots by the body's enzymes. This carries an increased risk of bleeding so is generally only used for specific situations (such as severe stroke or a massive pulmonary embolism).<ref>{{cite journal | vauthors = Tran HA, Gibbs H, Merriman E, Curnow JL, Young L, Bennett A, Tan C, Chunilal SD, Ward CM, Baker R, Nandurkar H | title = New guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand for the diagnosis and management of venous [[thromboembolism]] | journal = The Medical Journal of Australia | volume = 210 | issue = 5 | pages = 227–235 | date = March 2019 | pmid = 30739331 | doi = 10.5694/mja2.50004 | hdl = 11343/285435 | s2cid = 73433650 | hdl-access = free }}</ref>

===Surgery===
Arterial thrombosis may require surgery if it causes [[acute limb ischemia]].{{citation needed|date=July 2021}}

===Endovascular treatment===
Mechanical clot retrieval and catheter-guided thrombolysis are used in certain situations.<ref>{{cite journal |last1=Berkhemer |first1=Olvert A. |last2=Fransen |first2=Puck S.S. |last3=Beumer |first3=Debbie |last4=van den Berg |first4=Lucie A. |last5=Lingsma |first5=Hester F. |last6=Yoo |first6=Albert J. |last7=Schonewille |first7=Wouter J. |last8=Vos |first8=Jan Albert |last9=Nederkoorn |first9=Paul J. |last10=Wermer |first10=Marieke J.H. |last11=van Walderveen |first11=Marianne A.A. |last12=Staals |first12=Julie |last13=Hofmeijer |first13=Jeannette |last14=van Oostayen |first14=Jacques A. |last15=Lycklama à Nijeholt |first15=Geert J. |last16=Boiten |first16=Jelis |last17=Brouwer |first17=Patrick A. |last18=Emmer |first18=Bart J. |last19=de Bruijn |first19=Sebastiaan F. |last20=van Dijk |first20=Lukas C. |last21=Kappelle |first21=L. Jaap |last22=Lo |first22=Rob H. |last23=van Dijk |first23=Ewoud J. |last24=de Vries |first24=Joost |last25=de Kort |first25=Paul L.M. |last26=van Rooij |first26=Willem Jan J. |last27=van den Berg |first27=Jan S.P. |last28=van Hasselt |first28=Boudewijn A.A.M. |last29=Aerden |first29=Leo A.M. |last30=Dallinga |first30=René J. |last31=Visser |first31=Marieke C. |last32=Bot |first32=Joseph C.J. |last33=Vroomen |first33=Patrick C. |last34=Eshghi |first34=Omid |last35=Schreuder |first35=Tobien H.C.M.L. |last36=Heijboer |first36=Roel J.J. |last37=Keizer |first37=Koos |last38=Tielbeek |first38=Alexander V. |last39=den Hertog |first39=Heleen M. |last40=Gerrits |first40=Dick G. |last41=van den Berg-Vos |first41=Renske M. |last42=Karas |first42=Giorgos B. |last43=Steyerberg |first43=Ewout W. |last44=Flach |first44=H. Zwenneke |last45=Marquering |first45=Henk A. |last46=Sprengers |first46=Marieke E.S. |last47=Jenniskens |first47=Sjoerd F.M. |last48=Beenen |first48=Ludo F.M. |last49=van den Berg |first49=René |last50=Koudstaal |first50=Peter J. |last51=van Zwam |first51=Wim H. |last52=Roos |first52=Yvo B.W.E.M. |last53=van der Lugt |first53=Aad |last54=van Oostenbrugge |first54=Robert J. |last55=Majoie |first55=Charles B.L.M. |last56=Dippel |first56=Diederik W.J. |title=A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke |journal=New England Journal of Medicine |date=January 1, 2015 |volume=372 |issue=1 |pages=11–20 |doi=10.1056/NEJMoa1411587 |pmid=25517348 |display-authors=etal|hdl=2066/153000 |s2cid=9499117 |url=https://research.utwente.nl/en/publications/a-randomized-trial-of-intraarterial-treatment-for-acute-ischemic-stroke(ec0aa0f7-d007-4590-8ea1-a610e648f3a3).html |hdl-access=free }}</ref>

===Antiplatelet agents===
Arterial thrombosis is platelet-rich, and inhibition of platelet aggregation with [[antiplatelet drug]]s such as [[aspirin]] may reduce the risk of recurrence or progression.<ref>{{Cite web|title=Aspirin Monograph for Professionals|url=https://www.drugs.com/monograph/aspirin.html|access-date=June 9, 2020|website=Drugs.com|language=en}}</ref>

=== Targeting ischemia/reperfusion injury ===
{{Main|Reperfusion injury}}
With reperfusion comes ischemia/reperfusion (IR) injury (IRI), which paradoxically causes cell death in reperfused tissue<ref name="Grace 637–647">{{Cite journal|last=Grace|first=P. A.|date=May 1994|title=Ischaemia-reperfusion injury|journal=The British Journal of Surgery|volume=81|issue=5|pages=637–647|issn=0007-1323|pmid=8044536|doi=10.1002/bjs.1800810504|s2cid=34608929}}</ref> and contributes significantly to post-reperfusion mortality and morbidity.<ref>{{Cite journal|last1=Yellon|first1=Derek M.|author1-link=Derek M. Yellon|last2=Hausenloy|first2=Derek J.|date=September 13, 2007|title=Myocardial Reperfusion Injury|journal=New England Journal of Medicine|volume=357|issue=11|pages=1121–1135|doi=10.1056/nejmra071667|pmid=17855673|issn=0028-4793}}</ref><ref>{{Cite journal|last1=Bai|first1=Jilin|last2=Lyden|first2=Patrick D.|date=January 19, 2015|title=Revisiting Cerebral Postischemic Reperfusion Injury: New Insights in Understanding Reperfusion Failure, Hemorrhage, and Edema|journal=International Journal of Stroke|volume=10|issue=2|pages=143–152|doi=10.1111/ijs.12434|pmid=25598025|s2cid=25953179|issn=1747-4930}}</ref> For example, in a feline model of intestinal ischemia, four hours of ischemia resulted in less injury than three hours of ischemia followed by one hour of reperfusion.<ref name="Grace 637–647"/> In ST-elevation myocardial infarction (STEMI), IRI contributes up to 50% of final infarct size despite timely primary percutaneous coronary intervention. This is a key reason for the continued high mortality and morbidity in these conditions, despite endovascular reperfusion treatments and continuous efforts to improve timeliness and access to these treatments. Hence, protective therapies are required to attenuate IRI alongside reperfusion in acute ischemic conditions to improve clinical outcomes.<ref name="Ho 1">{{Cite journal|last1=Ho|first1=Andrew Fu Wah|last2=Jun|first2=Chong|last3=Ong|first3=Marcus Eng Hock|last4=Hausenloy|first4=Derek J.|date=April 2019|title=Remote Ischemic Conditioning in Emergency Medicine—Clinical Frontiers and Research Opportunities|journal=SHOCK|volume=53|issue=3|pages=269–276|doi=10.1097/SHK.0000000000001362|pmid=32045394|s2cid=149537443|issn=1073-2322|url=https://discovery.ucl.ac.uk/id/eprint/10093574/1/Hausenloy_Manuscript%2023%20Mar%202019%20accepted%20version.pdf}}</ref> Therapeutic strategies that have potential to improve clinical outcomes in reperfused STEMI patients include [[remote ischemic conditioning]] (RIC), exenatide, and metoprolol. These have emerged amongst a multitude of cardioprotective interventions investigated with largely neutral clinical data.<ref>{{Cite journal|last1=Hausenloy|first1=Derek J.|last2=Botker|first2=Hans Erik|last3=Engstrom|first3=Thomas|last4=Erlinge|first4=David|last5=Heusch|first5=Gerd|last6=Ibanez|first6=Borja|last7=Kloner|first7=Robert A.|last8=Ovize|first8=Michel|last9=Yellon|first9=Derek M.|date=April 26, 2016|title=Targeting reperfusion injury in patients with ST-segment elevation myocardial infarction: trials and tribulations|journal=European Heart Journal|volume=38|issue=13|pages=935–941|doi=10.1093/eurheartj/ehw145|pmid=27118196|issn=0195-668X|pmc=5381598}}</ref> Of these, RIC has the most robust clinical evidence, especially in the context of STEMI, but also emerging for other indications such as acute ischemic stroke and aneurysmal subarachnoid hemorrhage.<ref name="Ho 1"/>

=== Neonatal thrombosis ===
Treatment options for full-term and preterm babies who develop thromboembolism include expectant management (with careful observation), nitroglycerin ointment, [[pharmacological therapy]] (thrombolytics and/or anticoagulants), and surgery.<ref name=":1" /> The evidence supporting these treatment approaches is weak. For anticoagulant treatment, it is not clear if unfractionated and/or low molecular weight heparin treatment is effective at decreasing mortality and serious adverse events in this population.<ref name=":1" />  There is also insufficient evidence to understand the risk of adverse effects associated with these treatment approaches in term or preterm infants.<ref name=":1" />

== See also ==
* [[Blood clotting tests]]
* [[Disseminated intravascular coagulation]]
* [[Hepatic artery thrombosis]]
* [[Thrombotic microangiopathy]]

== References ==
{{reflist}}

===Bibliography===
* {{cite book | last = Brunner | first = Lillian | title = Brunner & Suddarth's textbook of medical-surgical nursing | publisher = Wolters Kluwer Health/Lippincott Williams & Wilkins | location = Philadelphia | year = 2010 | isbn = 978-0-7817-8590-7 }}
* {{cite book | last = Copstead | first = Lee | title = Pathophysiology | publisher = Elsevier | location = St. Louis, Mo | year = 2013 | isbn = 978-1-4557-2650-9 }}
* {{cite book | last = Hoffman | first = Barbara | title = Williams gynecology | publisher = McGraw-Hill Medical | location = New York | year = 2012 | isbn = 978-0-07-171672-7 }}
* {{cite book | last = Moliterno | first = David | title = Therapeutic advances in thrombosis | publisher = Wiley-Blackwell | location = Chichester, West Sussex | year = 2013 | isbn = 978-1-4051-9625-3 }}
* {{cite book |last=Abele |first=H |title=Atlas of gynecologic surgery |publisher=Thieme |location=Stuttgart |year=2014 |isbn=978-3-13-650704-9 }}

== External links ==
* {{Commons category-inline}}
{{Medical resources
|  DiseasesDB      =
|  ICD10           = {{ICD10|I|80||i|80}}-{{ICD10|I|82||i|80}}
|  ICD9            = {{ICD9|437.6}}, {{ICD9|453}}, {{ICD9|671.5}}, {{ICD9|671.9}}
|  ICDO            =
|  OMIM            =
|  MedlinePlus     =
|  eMedicineSubj   =
|  eMedicineTopic  =
|  MeshID          = D013927
}}

{{Vascular diseases}}
{{Bleeding and clotting disorders|us=y}}
{{Authority control}}

[[Category:Hematology]]