Acute Thromboembolic Complications Research Articles

Unified Scale for Assessing the Risk of Thromboembolic Complications – Family Doctor’s Tool for COVID-19 Pandemic

At present one of the most discussed medical problem is a COVID-19 pandemic. The world has already registered 274 408 291 cases of infection, and 5 365 361 lethal consequences. This disease is already known for almost two years, but there are still no clear understanding of its pathophysiology, clinical course and optimal therapeutic tactics. In Ukraine during this period, 3,324,999 patients with COVID-19 were registered, 92,929 people died. It is known that in the course of the COVID-19, severe thromboeembolic complications are often observed. That is why the most important element of therapy in case of acute thromboembolic complications is the timely use of thromboprophylaxis. The objective: is to develop an integrative scale that will summarize the conditions associated with the risk of thrombogenic complications. Materials and methods. The literature was analyzed on the E-library, PubMed, Scopus and Web of Science Core Collection databases to study questionnaires that were previously used in the patients with a therapeutic profile. 143 patients were examined, including 119 healthy people of all ages and 24 patients with metabolic syndrome (MS) over 60 years. General clinical, neurological, instrumental and laboratory examination were conducted. Results. The «Unified scale for assessing the risk of thromboembolic complications» was developed, containing 17 questions and allowing to assess the presence of risk factors and the prognosis of thromboembolic complications. The idea of creating arose on the basis of many years of experience in studying the issues of hemorheological properties of blood, microcirculation and endothelial function in persons of different ages on the basis of the Department of Clinical Physiology and Pathology of Internal Organs of the State Institution «D. F. Chebotarev Institute of Gerontology NAMS Ukraine» under the leadership of acad. NAMS of Ukraine Korkushko O.V. The questions used in the «Thromboembolic Complications Risk Assessment Scale» are intuitive and self-explanatory. It can be used in the form of a survey with a doctor, a nurse, and also independently in the form of a patient survey. The most convenient form of use is independently in the form of a questionnaire, and the most promising is when studying the health status of individuals in large samples, for example, in communities. The link to this questionnaire (https://forms.gle/XZwsGp5GaVuNqZeS9) was presented for the first time at the Ukrainian scientific and practical conference with international participation «Primary health care – the main component of health care in Ukraine (for the World Family Doctor Day)» of the P. L. Shupik (May 19–20, 2021). Conclusion. Blood circulation disturbances are accompanied by considerable number of pathological conditions, where early interventions and understanding of pathological mechanisms will reduce the risk of complications and prevent fatal consequences. The developed questionnaire allows, from the standpoint of both a doctor and a patient, to assess the risk of thromboembolic complications and identify risk factors for the development of thrombosis in routine clinical practice.

Venous thromboembolism in surgical practice.

A statistical retrospective analysis of the results of treatment of patients undergoing inpatient treatment in the surgical clinic, proctology and urology departments for 5 years was conducted, total number of patients – 27771, of them operated – 14849 (53.5%), postoperative mortality – 448 patients (3.0%), the overall mortality – 989 patients (3.6%). According to the analysis of the medical documentation, the total number of patients with pulmonary embolism (PE) was 98 (0.35%), the number of patients diagnosed during treatment – 56 (57.1%), at the time of pathoanatomical examination – 42 (42.9%); in 72 patients PE was directly responsible for death, 26 patients were cured by conservative methods. Of 98 patients with PE in 56 (56.1%), the main disease was oncological disease, in most cases in neglected form with distant metastases. A reduction in postoperative lethality by 40% was obtained, the reason for which, in our opinion, are: mandatory adherence to the recommended timing of the prevention of acute thromboembolic complications; prolongation of the prophylaxis term in patients who have undergone major surgical interventions or with postoperative complications that lead to a prolonged limitation of the patients' motor activity; a wider use of low molecular weight heparins.

Glycoprotein IIb/IIIa Inhibitors in Prevention and Rescue Treatment of Thromboembolic Complications During Endovascular Embolization of Intracranial Aneurysms

Thromboembolic complications remain a major risk of endovascular neurosurgery during the treatment of intracranial aneurysms, despite the use of therapeutic heparinization and oral antiplatelet therapy when indicated. Glycoprotein (GP) IIb/IIIa inhibitors target a nonredundant pathway of platelet aggregation following adhesion and activation. Initially established and implemented in the cardiovascular arena, this drug class has provided a new tool in the neurovascular armamentarium as well. Numerous case reports, case series, and retrospective reviews have evaluated the safety and efficacy of abciximab, eptifibatide, and tirofiban in the treatment of acute thromboembolic complications during the endovascular treatment of intracranial aneurysms. The use of this drug class has also been found to be beneficial as a prophylactic agent, providing ischemia protection during the placement of intracranial stents, flow diverters, and thrombogenic coils in the setting of subarachnoid hemorrhage and during elective aneurysmal embolization. While the current published literature clearly establishes efficacy and safety of GP IIb/IIIa inhibitors in the prevention of thromboembolic complications, there does not yet exist an established protocol for their administration in endovascular neurosurgery. This review provides a comprehensive evaluation of the current published literature pertaining to the use of all available GP IIb/IIIa inhibitors for thromboembolic complications, providing recommendations for dosing and administration of abciximab, eptifibatide, and tirofiban based on previously published rates of efficacy and intracranial hemorrhage.

Clinical Impact of Flat Panel Volume CT Angiography in Evaluating the Accurate Intraoperative Deployment of Flow-Diverter Stents.

The deployment of flow-diverter stents may be difficult to analyse on regular DSA. The purpose of our study was to investigate the clinical impact of stent-dedicated flat panel volume CT angiography to evaluate intraoperatively the satisfactory deployment of flow-diverter stents. From January 2009 to April 2015, 83 consecutive patients (mean age, 51 years; 62 women) were treated in our institution with flow-diverter stents. Eighty-seven aneurysms (82 unruptured, 5 ruptured; 77 anterior, 10 posterior circulation) were treated in these 83 patients (4 patients had 2 aneurysms, both treated by means of flow-diverter stents). One patient was treated for a traumatic carotid cavernous fistula. In 80% of the cases (68/85) a flat panel volume CT angiography was performed in the angiographic suite just after the flow-diverter stent deployment. Stent visualization was assessed by 2 independent reviewers. The clinical impact of stent malapposition was evaluated. Flow-diverter stent visualization was satisfactory in 73.5% of the cases. In 2 cases (2.9%) the flat panel volume CT angiography prompted the operator to perform an additional intrastent angioplasty for a condition that was previously underestimated. Four patients (4.7%) experienced acute thromboembolic complications; 3 others had delayed thromboembolic complications. Only 1 of these patients had thromboembolic complications (acute or delayed) related to stent misdeployment, which was easily managed intraoperatively with no clinical consequence. Flat panel volume CT angiography is an interesting tool to depict flow-diverter stent misdeployment and may encourage the operator to perform intrastent angioplasty (2.9% of the cases in our experience) to reduce the risks of thromboembolic complications.

Гострі тромбоемболічні ускладнення у пацієнтів з хірургічною патологією органів черевної порожнини

Частота виникнення гострих тромбоемболічних ускладнень (ГТЕУ) щорічно збільшується та складає понад 100 випадків на 100 000 населення. В останні роки ГТЕУ стали займати провідне місце серед післяопераційних за рахунок впровадження нових хірургічних технологій, удосконалення техніки операційних втручань, високого рівня сучасної анестезіології та інтенсивної терапії, які привели до зниження операційної летальності та зменшення виникнення специфічних післяопераційних ускладнень. Незважаючи на різноманіття запропонованих схем щодо призначення антикоагулянтів із метою профілактики виникнення ГТЕУ, кількість виникнення останніх викликає необхідність більш детального вивчення факторів ризику ГТЕУ та удосконалення існуючих схем профілактики й лікування цієї патології. Проведено статистичний ретроспективний аналіз результатів лікування пацієнтів із гострою хірургічною патологією органів черевної порожнини, які перебували на стаціонарному лікуванні в КЗ “ШМКЛ” ДОР” у 2013–2015 рр. За результатами аналізу медичної документації: загальна кількість пацієнтів із ГТЕУ (ТЕЛА) – 72 (0,43 %), кількість пацієнтів, яким діагноз було встановлено під час лікування, – 34 (47,2 %), під час патологоанатомічної експертизи – 38 (52,8 %); у 51 пацієнта ТЕЛА виявилась безпосередньою причиною смерті, 21 пацієнта вилікувано консервативними методами у відділенні інтенсивної терапії. У пацієнтів із невідкладною хірургічною патологією, особливо з онкологічною патологією, необхідно визначати фактори ризику розвитку ГТЕУ, призначати профілактику або лікування останніх відповідно до затверджених стандартів (протоколів) надання медичної допомоги.

Arterial stiffness in the light of thromboembolic complications in elderly patients with atrial fibrillation

According to available data reported by numerous national and international studies, one of the parameters reflecting the degree of lesioning of the vascular wall is arterial stiffness, which makes a fundamental contribution to the risk of developing cardiovascular diseases and the total cardiovascular mortality, especially in the elderly. Patients with cardiac arrhythmias, especially with atrial fibrillation (AF), deserve our special care, since it is this group of patients that is susceptible to a high risk of developing primary and recurrent thromboembolic episodes. This category of patients had a very high risk of death and invalidation, considering the age factor and comorbidity of the pathology. The analysis of factors involved in the development of not only AF, but also its complications, is a task necessary to improve technologies of correction. In view of this, the parameter of vascular-wall stiffness, being one of the mechanisms involved in AF maintenance and a risk factor for the development of acute thromboembolic complications, primarily stroke, should be given very serious consideration. This survey aims to discuss the results of studies devoted to arterial stiffness in patients with atrial fibrillation (AF), as well as the issues related to the risk of developing thromboembolic complications in this category of patients.

Does temproray bilateral balloon occlusion of the common iliac arteries reduce the need for intra-operative blood transfusion in cases of placenta accretism?

Bilateral balloon occlusion has been employed as a prophylactic measure in cases of placenta accretism prior to caesarean section with the aim of reducing blood loss and its associated morbidity/mortality. There is however no clear consensus on its efficacy in the current literature. The objective of this study was to assess the efficacy of bilateral balloon occlusion of the common iliac arteries (CIA) in reducing intra-operative morbidity in cases of placenta accretism. The databases of the pathology department and radiology interventional suite were reviewed over a nine year period. Fifty-two cases of confirmed placental accretism who underwent caesarean section with or without hysterectomy were identified and divided into two groups. Twenty-five cases had temporary occlusion of the common iliac arteries (CIA) during delivery and these were considered the study group. The reminder 27 cases did not have temporary occlusion of the CIA and were considered the control group. The two groups were compared based on gravidity, age group, post-operative haemoglobin, drop in haemoglobin, estimated blood loss (EBL), transfusion requirement and the histopathological sub-types of placenta accretism. There was no statistically difference between the study and the control groups regarding EBL, post-operative haemoglobin drop, transfusion requirement or in the placenta accretism histopathological subtype. Two cases in the study group had acute thromboembolic complications. Both groups had a single patient requiring a massive intra-operative transfusion. Our study was not able to detect a significant difference in blood loss or blood product requirement between patients who underwent CIA balloon in the setting of caesarean section for placenta accreta. This remains a challenging scenario requiring a multidisciplinary approach.

Continuous warfarin versus periprocedural dabigatran to reduce stroke and systemic embolism in patients undergoing catheter ablation for atrial fibrillation or left atrial flutter

Left atrial catheter ablation for patients with atrial fibrillation (AF) requires periprocedural anticoagulation to minimize thromboembolic complications. High rates of major bleeding complications using dabigatran etexilate for periprocedural anticoagulation have been reported, raising concerns regarding its safety during left atrial catheter ablation. We sought to evaluate the safety and efficacy of a dabigatran use strategy versus warfarin, at a single high-volume AF ablation center. We performed a retrospective analysis on consecutive patients undergoing left atrial ablation at Vanderbilt Medical Center from January 2011 through August 2012 with a minimum follow-up of 3months. Patient cohorts were divided into two groups, those utilizing dabigatran etexilate pre- and post-ablation and those undergoing ablation on dose-adjusted warfarin, with or without low-molecular-weight heparin bridging. Dabigatran was held 24-30h pre-procedure and restarted 4-6h after hemostasis was achieved. We evaluated all thromboembolic and bleeding complications at 3months post-ablation. A total of 254 patients underwent left atrial catheter ablation for atrial fibrillation or left atrial flutter. Periprocedural anticoagulation utilized dabigatran in 122 patients and warfarin in 135 patients. Three late thromboembolic complications occurred in the dabigatran group (2.5%), compared with one (0.7%) in the warfarin group (p = 0.28). The dabigatran group had similar minor bleeding (2.5 vs. 7.4%, p = 0.07), major bleeding (1.6 vs. 0.7%, p = 0.51), and composite of bleeding and thromboembolic complications (6.6 vs. 8.9%, p = 0.49) when compared to warfarin. There were no acute thromboembolic complications in either group (<24h post-ablation). In patients undergoing left atrial catheter ablation for AF or left atrial flutter, use of periprocedural dabigatran etexilate provides a safe and effective anticoagulation strategy compared to warfarin. A prospective randomized study is warranted.

Biomarkers in acute coronary artery disease

Death from coronary artery disease is by far the leading cause of death worldwide. There is no doubt that a better understanding of atherothrombosis has guided development of improved diagnostic facilities as well as revascularization technologies in combination with current antithrombotic strategies that have altogether impressively reduced acute thromboembolic complications and death from cardiovascular causes within the last decades. However, the rate of ischemic complications even after optimal revascularization and medical therapy remains high. Similarly, morbidity and death associated with chronic ischemic heart disease and ischemic cardiomyopathy respectively are constantly rising. Therefore, there is still a strong need for effective primary prevention strategies, fast and accurate diagnostic procedures as well as for new and smart antithrombotic drugs. The review focuses on cardiac troponins, as relevant markers of myocardial necrosis, currently used in the diagnostic process of acute coronary syndrome. Furthermore, we will discuss the potential role of copeptin, a new marker of acute endogenous stress in acute coronary syndrome patients, as faster diagnosis might lead to faster treatment as well as improved short- and long-term outcome following acute coronary syndrome. Finally, platelets are an old, yet rediscovered biomarker for ischemic cardiovascular outcomes that might be used to estimate the individual bleeding or thrombotic risk and to tailor antiplatelet therapy.

Cytokines in the Pathogenesis of Atherosclerosis

Research during the last two decades established atheromatous lesions as active sites of inflammation and immune responses, contrasting to the traditional view of atherosclerosis as an acellular lesion composed of lipid deposits. In particular, cytokines appear to orchestrate the chronic development of atherosclerosis, eventually leading to the formation of complex atherosclerotic plaques, which can trigger acute thromboembolic complications, such as myocardial infarction or stroke. Indeed the rupture-prone plaque, characterized by a thin fibrous cap overlaying a voluminous lipid core, exhibits accumulation of various pro-inflammatory cytokines. These cytokines may control the clinical consequences of plaques by mediating infiltration and accumulation of immunocompetent cells, directing the turnover of fibrillar collagens (governing the fragility of the fibrous cap), or enhancing foam cell formation and thrombogenicity of the lipid core, among other processes outlined in this review. Thus, understanding the role of cytokines in the pathophysiology of the atherosclerotic plaque might provide a promising therapeutic avenue for this prevalent human disease. This review will focus on members of the interleukin, tumor necrosis factor, and interferon families of cytokines in modulating key processes of atherogenesis.

Long-Term Therapy with Subcutaneous Heparin during Pregnancy

35 pregnant women (37 pregnancies) were treated with subcutaneous and/or intravenous heparin because of acute thromboembolic complications (TE) or as prophylaxis against TE. 25 pregnancies were uncomplicated. The most frequent complication was incipient premature labor, which occurred in 7 women. Other complications were retention placentae, twin pregnancies, ablatio placentae and minor hematomas. No serious bleeding complications occurred. The treatment did not seem to affect the children. The antithrombin III (AT) level measured with the chromogenic substrate, S-2238, and platelet counts were analyzed in 16 women. Liver function was studied in 13 of them. A significant decrease in AT occurred initially in both groups and normalization was noted during long-term heparin treatment. Platelet count and liver function were mainly unchanged.

Pathogenesis of the coagulation defect developing during pathological plasma proteolytic ("fibrinolytic") states. II. The significance, mechanism and consequences of defective fibrin polymerization.

A clinical syndrome characterized by a coagulation defect, hypofibrinogenemia, often an associated hemorrhagic diathesis and manifestations of whole blood or plasma fibrinolysis (spontaneous lysis of whole blood or plasma clots), has long been recognized. Usually developing acutely after the trauma of surgery or in association with certain obstetric complications, it may also present as a chronic syndrome complicating the course of long-term medical disease (reviews noted in References 1, 2). Moreover, the iatrogenic induction of the syndrome, usually in a mild form, frequently accompanies the treatment of the acute thromboembolic complications of vascular disease by enzymatic means (3-6).