Administration Of Anticoagulant Therapy Research Articles

Strategies for Perioperative Anticoagulant Reversal in Orthopedic Surgery: A Review.

The administration of anticoagulation therapy during major orthopedic surgeries is a clinical challenge due to the risk of thrombotic events and bleeding complications. This review aims to evaluate the current strategies and emerging developments in perioperative anticoagulation reversal. We conducted a literature review on the management of perioperative anticoagulant therapy, which included the current status of anticoagulant reversal agents, as well as personalized medicine, pharmacogenomics, artificial intelligence (AI), and novel drug delivery systems. The review indicates that reversal agents such as idarucizumab and andexanet alfa are crucial in managing bleeding associated with direct oral anticoagulants (DOACs). Personalized medicine, guided by pharmacogenomics, allows for tailored anticoagulation regimens. AI and machine learning (ML) algorithms can enhance the predictive capabilities for bleeding and thrombotic risks. Additionally, nanotechnology and biomarkers offer innovative approaches to drug delivery and personalized treatment. Integrating evidence-based guidelines with innovative reversal agents, personalized medicine, AI and nanotechnology opens a new era in perioperative anticoagulation management. These advancements can ensure patient safety, minimize bleeding risks, and improve surgical outcomes. Future research should focus on the clinical validation of these strategies to ensure their effectiveness across diverse patient populations.

Modern Strategies of Anticoagulant and Antiplatelet Therapy: Novel Approaches to Diagnosing the Hemostatic System using Laboratory and Instrumental Methods

Statement of the Problem: Impairment of the blood coagulation system remains a relevant issue in clinical practice. A striking example of this is the fact that despite the administration of anticoagulant therapy, up to 35% of COVID-19 patients were hospitalized in the intensive care unit with thromboembolic complications.

Contemporary Paradigm of Anticoagulant and Antiplatelet Therapy: Revolutionary Approaches to Assessing Blood Coagulation in the Laboratory and Using Instrumental Methods

Statement of the Problem: Impairment of the blood coagulation system remains a relevant issue in clinical practice. A striking example of this is the fact that despite the administration of anticoagulant therapy, up to 35% of COVID-19 patients were hospitalized in the intensive care unit with thromboembolic complications. Prophylactic and therapeutic methods for the hemostatic system, recommended by various protocols, have a general nature. Moreover, they introduce dissonance into the clinical clarity of appropriate anticoagulant and antiplatelet use and fail to provide practitioners with the necessary fundamental knowledge to understand the aspects of clinical tactics for correcting the hemostatic system. Uncertainties remain regarding how to correctly choose a specific anticoagulant and determine its effective dose based on individual clinical and laboratory data, which laboratory markers of the coagulation system should be investigated, and whether they always reflect the true picture of hemostasis. Methodology and Theoretical Orientation: This article briefly presents the main aspects of the functioning of the blood coagulation system, points of application for pharmacological agents, and provides objective information for clinicians about the mechanisms of action of major anticoagulants and antiplatelets. Effective and practical methods for assessing the hemostatic system are recommended. Findings: The proper correction of the hemostatic system can only be carried out by a highly qualified specialist - a clinical transfusiologist, who possesses a comprehensive understanding of the functioning of the coagulation and anticoagulation systems, the platelet and fibrinolysis systems, knows the points of application and mechanisms of action of the pharmacological agents and blood components used, and takes into account internal and external factors that influence hemostasis. Conclusion and Significance: Empirical prescription of anticoagulant and antiplatelet therapies, based solely on instructions and clinical protocols without objective comprehensive analysis of the hemostatic components, is not only ineffective but also life-threatening for the patient. Hemostasiogram (coagulogram) and D-dimer measurements cannot serve as the sole determining markers for monitoring the coagulation system. Evaluation of the blood coagulation system should only be carried out based on a comprehensive analysis of hemostasiogram data, complete blood count, thromboelastography (TEG), and data from all relevant systems.

Role of Calprotectin, IL-6, and CRP in Distinguishing Between Inflammatory Bowel Disease and Diarrhea Predominant Irritable Bowel Syndrome.

The early establishment of prophylaxis and immediate administration of anticoagulant therapy upon the diagnosis of venous thromboembolism should be the treatment objectives in these patients. The study aimed to determine the optimal cut-off point of Calprotectin, IL-6 (interleukin-6), CRP (C reactive protein) to differentiate UC, IBS-D. A cross-sectional descriptive study of 335 individuals ≥15 years old was performed, including 31 healthy controls, 215 with IBS-D, 71 diagnosed with UC, and 18 diagnosed with CD. Receiver Operating Characteristics (ROC), sensitivity, specificity, and area under curve (AUC) were computed. The results showed that the median value of calprotectin (IQR) in healthy participants was 20.0 (6.0 - 34.0) µg/g; 17,7 (8,7-38,9) µg/g in IBS-D group; 1710.0 (588 - 4260,0) µg/g in UC group; and 560.5 (177.8 - 1210.0) µg/g in CD group. Calprotectin concentration in IBD group including UC and CD was higher than IBS-D with p<0.05. The median value of CRP (range IQR) was 1,3 (0,9 - 2,3) mg/L in IBS-D group; 7.0 (2.4 -16.6) mg/L in UC group; and 10.1 (2.2 - 42.5) mg/L in CD group. CRP concentration in IBD group including UC and CD was higher than IBS-D with p<0.05. The median value of IL-6 (range IQR) was 2.3 (1.6 - 5.7) pg/mL in IBS-D group; 16.8 (9.4 - 47.0) pg/mL in UC group; and 9.4 (7.9 - 11.0) pg/mL in CD group. Calprotectin concentration in IBD group including UC and CD was higher than IBS-D with p<0.05. The optimal cut-off point of calprotectin that differentiated IBS-D from IBD was 110.5 µg/g, with sensitivity and specificity of 93.3% and 91.4%, respectively; of IL-6 was 7.2 pg/mL with sensitivity and specificity of 92.0% and 78.0%, respectively; of CRP of 2.4 mg/L had specific sensitivities of 83.3% and 86.0%, respectively. The Calprotectin immunoassay has the best value in discriminating between IBD and IBS-D.

Contemporary Concept of Anticoagulant and Antiplatelet Therapies A Fresh Perspective on Laboratory and Instrumental Assessment Methods

Statement of the Problem: Impairment of the blood coagulation system remains a relevant issue in clinical practice. A striking example of this is the fact that despite the administration of anticoagulant therapy, up to 35% of COVID-19 patients were hospitalized in the intensive care unit with thromboembolic complications. Prophylactic and therapeutic methods for the hemostatic system, recommended by various protocols, have a general nature. Moreover, they introduce dissonance into the clinical clarity of appropriate anticoagulant and antiplatelet use and fail to provide practitioners with the necessary fundamental knowledge to understand the aspects of clinical tactics for correcting the hemostatic system. Uncertainties remain regarding how to correctly choose a specific anticoagulant and determine its effective dose based on individual clinical and laboratory data, which laboratory markers of the coagulation system should be investigated, and whether they always reflect the true picture of hemostasis. Methodology and Theoretical Orientation: This article briefly presents the main aspects of the functioning of the blood coagulation system, points of application for pharmacological agents, and provides objective information for clinicians about the mechanisms of action of major anticoagulants and antiplatelets. Effective and practical methods for assessing the hemostatic system are recommended. Findings: The proper correction of the hemostatic system can only be carried out by a highly qualified specialist - a clinical transfusiologist, who possesses a comprehensive understanding of the functioning of the coagulation and anticoagulation systems, the platelet and fibrinolysis systems, knows the points of application and mechanisms of action of the pharmacological agents and blood components used, and takes into account internal and external factors that influence hemostasis. Conclusion and Significance: Empirical prescription of anticoagulant and antiplatelet therapies, based solely on instructions and clinical protocols without objective comprehensive analysis of the hemostatic components, is not only ineffective but also life-threatening for the patient. Coagulogram and D-dimer measurements cannot serve as the sole determining markers for monitoring the coagulation system. Evaluation of the blood coagulation system should only be carried out based on a comprehensive analysis of coagulogram data, complete blood count, thromboelastography (TEG), and data from all relevant systems.

A Case of Dural Arteriovenous Fistula Following Cerebral Venous Sinus Thrombosis Associated with the COVID-19 Vaccine.

Cerebral venous sinus thrombosis (CVST) is one of the rare and severe complications of coronavirus disease 2019 (COVID-19) vaccines. CVST has also been reported to develop into dural arteriovenous fistula; however, there were no reports of dural arteriovenous fistula associated with COVID-19 vaccine-induced cerebral venous sinus thrombosis. Here, we describe a rare case of a transverse-sigmoid sinus dural arteriovenous fistula followed by CVST due to COVID-19 vaccination. A 70-year-old patient presented with headache five days after receiving a second dose of COVID-19 vaccine. MRI showed a CVST in the superior sagittal sinus, left transverse sinus, and left sigmoid sinus. His headache improved after the administration of anticoagulant therapy. Six months later, a similar headache recurred, and cerebral angiography demonstrated a dural arteriovenous fistula in the left transverse sigmoid sinus and convexity dural arteriovenous fistulas in the left parietal cortex. The patient was treated twice with two sessions of transarterial embolization, and the shunts were completely occluded. His symptoms improved, and he was discharged with a modified Rankin Scale score of 0. Dural arteriovenous fistula can develop after CVST in association with COVID-19 vaccination.

Multisystem inflammatory syndrome, probably associated with SARS-CoV-2, complicated by thrombus in the right atrium, in a child

Aim. Clinical case report of multisystem inflammatory syndrome, probably associated with COVID-19 and complicated by large thrombus in the right atrium in a child highlights the problems of monitoring, treatment, and the possibility of their solution. Presentation of a clinical case. We demonstrate one of the cases of multisystem inflammatory syndrome (MIS-C), which meets WHO criteria. In a child with a severe course of the disease and symptoms of hyperinflammation, on the 16th day from the onset of the disease, a positive effect was registered on the introduction of human normal immunoglobulin for intravenous administration and glucocorticosteroids. But on the day 27 of the disease, despite administration of anticoagulant therapy, a large blood clot was found in the right atrium cavity. Operation was performed with removal of the thrombus from the right atrium under artificial blood circulation and the child was discharged in satisfactory condition to continue treatment in an outpatient setting on the day 56 of the disease. Conclusions. Timely diagnosis of MIS-C in children with fever, signs of inflammation and organ dysfunction during the pandemic spread of COVID-19 and reasonable administration of intravenous immunoglobulin and steroids may reduce the inflammatory response and improve the prognosis. It is also important to conduct population-based prospective studies to optimize thromboprophylaxis in children with COVID-19 and MIS-C.

Case Report: Case report: Administration of anticoagulant therapy after neuro-anesthesia procedure for hemorrhagic stroke patients with COVID-19 complications and its ethical and medicolegal consideration

Background: Ethical dilemmas can occur in any situation in clinical medicine. In patients undergoing neuro-anesthesia for surgical procedure evacuation of intracerebral hemorrhage with a history of hemorrhagic stroke, anticoagulants should not be given because they can cause recurrent bleeding. Meanwhile, at the same time, the patient could also be infected with coronavirus disease 2019 (COVID-19), one of treatment is the administration of anticoagulants. Methods: A case report. A 46-year-old male patient was admitted to hospital with a loss of consciousness and was diagnosed with intracerebral hemorrhage due to a hemorrhagic stroke and was confirmed positive for COVID-19. Giving anticoagulants to patients is considered counterproductive so, an ethical dilemma arises. For this reason, a joint conference was held to obtain the best ethical and medicolegal solutions for the patient. Results: By using several methods of resolving ethical dilemmas such as basic ethical principles, supporting ethical principles, and medicolegal considerations, it was decided that the patient was not to be given anticoagulants. Conclusions: Giving anticoagulants to hemorrhagic stroke patients is dangerous even though it is beneficial for COVID-19 patients, so here the principle of risk-benefit balance is applied to patients who prioritize risk prevention rather than providing benefits. This is also supported by the prima facie principle by prioritizing the principle of non-maleficence rather than beneficence, the minus malum principle by seeking the lowest risk, and the double effect principle by making the best decision even in a slightly less favorable way as well as the medicolegal aspect by assessing patient safety and risk management.

The algorithm of decision-making in administration of anticoagulant therapy due to COVID‑19. Review

There is a hypothesis that on its late complicated stages, coronavirus disease of 2019 (COVID‑19) represents an endothelial disease. According to Peter’s Libbi data (2020), the endothelial monolayer measures up to 7000 m2 in surface area. The endothelial functions include anticoagulant, antiplatelet, anti‑inflammatory, vasomotion, and structure. The aim of the review was to figure out COVID‑19 logistics from the standpoint of its pathogenesis, in particular its thrombotic complications, to summarize data on the choice of an anticoagulant, its dose and duration of use. COVID‑19 is a new disease with the lack of evidence‑based data, however, its per‑syndrome analysis results in conclusion that the most part of acute and post‑COVID complications refer to thromboembolic ones. According to the recommendations of the European Society of Cardiology on diagnostic and treatment of thromboembolism, the need for thromboembolism prevention is defined in case of respiratory failure, installed intravenous catheters, infection (specifically pneumonia), bed rest, elderly age, etc. The adherence to evidence‑based recommendations will allow one to administer rational anticoagulation therapy without harm to a patient. It concerns both patients, who are on anticoagulant therapy at hospital admission, and those who requires its new administration. The following questions are mostly frequent arising in doctors: How one should manage a patient with active bleeding, or platelet levels &lt; 25 · 109/ L, or with congenital abnormality of coagulation? What types of blood chemistry should be considered when administering anticoagulant? What therapy should be administered at discharge? Compliance with clear anticoagulation algorithms will prevent thromboembolic complications, further damage to organs and systems, and significant bleeding.&#x0D; &#x0D;

Computational modeling of blood component transport related to coronary artery thrombosis in Kawasaki disease.

Coronary artery thrombosis is the major risk associated with Kawasaki disease (KD). Long-term management of KD patients with persistent aneurysms requires a thrombotic risk assessment and clinical decisions regarding the administration of anticoagulation therapy. Computational fluid dynamics has demonstrated that abnormal KD coronary artery hemodynamics can be associated with thrombosis. However, the underlying mechanisms of clot formation are not yet fully understood. Here we present a new model incorporating data from patient-specific simulated velocity fields to track platelet activation and accumulation. We use a system of Reaction-Advection-Diffusion equations solved with a stabilized finite element method to describe the evolution of non-activated platelets and activated platelet concentrations [AP], local concentrations of adenosine diphosphate (ADP) and poly-phosphate (PolyP). The activation of platelets is modeled as a function of shear-rate exposure and local concentration of agonists. We compared the distribution of activated platelets in a healthy coronary case and six cases with coronary artery aneurysms caused by KD, including three with confirmed thrombosis. Results show spatial correlation between regions of higher concentration of activated platelets and the reported location of the clot, suggesting predictive capabilities of this model towards identifying regions at high risk for thrombosis. Also, the concentration levels of ADP and PolyP in cases with confirmed thrombosis are higher than the reported critical values associated with platelet aggregation (ADP) and activation of the intrinsic coagulation pathway (PolyP). These findings suggest the potential initiation of a coagulation pathway even in the absence of an extrinsic factor. Finally, computational simulations show that in regions of flow stagnation, biochemical activation, as a result of local agonist concentration, is dominant. Identifying the leading factors to a pro-coagulant environment in each case—mechanical or biochemical—could help define improved strategies for thrombosis prevention tailored for each patient.

P–358 Characteristics of patients with inherited thrombophilia and anticoagulant treatment in repeated implantation failure (RIF) and recurrent pregnancy loss (RPL)

Abstract Study question Do patients with inherited thrombophilia associated to RIF and RPL benefit from anticoagulant therapy? Summary answer Low molecular weight heparin (LMWH) in patients with medium and high risk of hereditary thrombophilia, associated with RIF could improve the reproductive prognosis. What is known already Thrombophilia is a condition that can be acquired and/or inherited genetically, that is characterized by the predisposition of patients to form venous and arterial thromboembolic events. Inherited thrombophilia has been associated with different complications during pregnancy, such as RPL. Genetic variants linked to hereditary thrombophilia can be classified by the thromboembolic risk: low (F12, F13A1, FGB), medium (MTHFR, PROCR, PROS1, SERPINC1, SERPINC1 PAI–1) and high (F2, F5, GP1BA), according to Martinez - Zamora. RPL rate may reduce with anticoagulant therapy. However, there is no conclusive evidence that prophylactic treatment improves the pregnancy rate in infertile women during IVF. Study design, size, duration We performed a prospective observational study which included patients referred to Ceras Clinic between March 2018 and March 2020, due to RPL (n = 38) and RIF (n = 40). All patients underwent genetic analysis for hereditary thrombophilia(F13, F2, F5, FGB, GP1BA, MTHFR C677T, MTHFR A1298C, PAI1,, PROCR, SERPIN1 CM910058, SERPIN 1 CM920113 ,F12, PROS1) by Sanger sequencing. The characteristics of anticoagulant therapy with clinical pregnancy rate and LBR were analyzed, using chi-squared test with STATA version 16. Participants/materials, setting, methods Patients have been included in the study according to their past medical history (stroke or myocardial infarction, personal or familiar history of deep vein thrombosis or pulmonary embolism, smoking, hormone replacement therapy), and reproductive history. Two groups were formed, the first group (n = 40) corresponds to RIF, and the second (n = 38), RPL. Genetic study of hereditary thrombophilia (11 genes) was performed to examine the genetic risk and assess the administration of anticoagulant therapy. Main results and the role of chance The prevalence of pathological antecedents in patients with RIF and RPL was not statistically significant (p &amp;gt; 0,05), indicating that the factors that contribute to poor reproductive outcomes in these two groups of patients could be similar. Patients with RIF had a medium risk of thrombophilia in 65%, followed by low risk in 32.5% and high risk in 2.5%. RPL group presented 78.95%, 15.79% and 5.26%, respectively. All patients with medium and high risk for trombophilia received anticoagulation. Clinical pregnancy rate (69.7%) and live birth rate (63.64%) were not statistically significant (p &amp;gt; 0.05) in RPL with anticoagulant therapy, compared to RPL group who did not received treatment (clinical pregnancy rate and live birth rate in 60%). Therefore, it is proposed that there may be other factors associated with abortions that require investigation. However, clinical pregnancy rate (77.14%) and live birth rate (74.29%) were statistically significant (p &amp;lt; 0.05) in RIF with anticoagulant therapy, compared to RIF group that did not received treatment (clinical pregnancy rate and live birth rate in 20%). This suggests that there could be a beneficial factor due to anticoagulation. Further studies are needed to assess that anticoagulant treatment could improve obstetric outcomes in patients with RIF and RPL. Limitations, reasons for caution The small number of patients assessed is the main limitation of this work. Larger studies must be designed to accurately determine participation of each mutation associated with recurrent implantation failure and recurrent pregnancy loss. The role of anticoagulant therapy should be evaluated in randomized clinical trials. Wider implications of the findings: Establishing a stronger evidence base implies that future studies should include large population groups. It is primordial to assess whether it is cost-effective to determine the risk of inherited thrombophilia in RIL and RPL, to increase the live birth rate by anticoagulant therapy. The information is controversial to this day. Trial registration number ‘not applicable’

2021 John N. Insall Award: Aspirin is effective in preventing propagation of infrapopliteal deep venous thrombosis following total knee arthroplasty.

The optimal management of an infrapopliteal deep venous thrombosis (IDVT) following total knee arthroplasty (TKA) remains unknown. The risk of DVT propagation and symptom progression must be balanced against potential haemorrhagic complications associated with administration of anticoagulation therapy. The current study reports on a cohort of patients diagnosed with IDVT following TKA who were treated with aspirin, followed closely for development of symptoms, and scanned with ultrasound to determine resolution of IDVT. Among a cohort of 5,078 patients undergoing TKA, 532 patients (695 TKAs, 12.6%) developed an IDVT between 1 January 2014 to 31 December 2019 at a single institution, as diagnosed using Doppler ultrasound at the first postoperative visit. Of the entire cohort of 532 patients with IDVT, 91.4% (486/532) were treated with aspirin (325 mg twice daily) and followed closely. Repeat lower limb ultrasound was performed four weeks later to evaluate the status of IDVT. Follow-up Doppler ultrasound was performed on 459/486 (94.4%) patients and demonstrated resolution of IDVT in 445/459 cases (96.9%). Doppler diagnosed propagation of IDVT to the popliteal vein had occurred in 10/459 (2.2%) cases. One patient with an IDVT developed a pulmonary embolus six weeks postoperatively. The results of this study demonstrate a low rate of IDVT propagation in patients managed with aspirin. Additionally, no significant bleeding episodes, wound-related complications, or other adverse events were noted from aspirin therapy. Cite this article: Bone Joint J2021;103-B(6 Supple A):18-22.

The safety of new oral anticoagulants for ischemic stroke and systemic embolism prevention in females with atrial fibrillation

The prevalence of atrial fibrillation is lower in females than in men, but the risk of stroke and systemic thromboembolism is comparable or even higher. Administration of anticoagulant therapy does not modify this difference. Two classes of non-vitamin K antagonist oral anticoagulants were studied in atrial fibrillation: direct thrombin inhibitors, like Dabigatran, and activated factor X inhibitors, like Rivaroxaban, Apixaban and Edoxaban. Response to oral anticoagulants could differ between the gender. This medication was evaluated in phase III randomized controlled trials. Non-vitamin K antagonist oral anticoagulants have been proved more efficacious than Warfarin for stroke and systemic embolism prevention in women, but conclusions regarding the safety and the bleeding are heterogeneous. As in men, before prescribing a NOAC to a female with AF, the stroke and the bleeding risk have to be carefully estimated. It is important that future studies to be targeted on comparison between of non-vitamin K antagonist oral anticoagulants versus Warfarin in females with non-valvular atrial fibrillation.

A case of iliopsoas hematoma as a complication of tetanus in a patient who did not receive anticoagulant therapy

BackgroundThe specific clinical feature of tetanus is whole body muscle spasms. These spasms are intensely painful and sometime lead to some injuries. Vertebral fractures have been reported as a common complication of tetanus, however iliopsoas hematoma is a rare complication. We describe a case of iliopsoas hematoma in a tetanus patient who had not been treated with any anticoagulant or antiplatelet agents.Case presentationA 72-year-old female patient was transferred to our hospital 7 days after the onset of tetanus. An iliopsoas hematoma was identified in her right iliopsoas muscle on computed tomography. There was no extravasation; thus, the hematoma improved with conservative therapy. There were no episodes that suggested a bleeding tendency, or no factors associated with hemorrhagic conditions.ConclusionThis is the first report of iliopsoas hematoma as a complication in a tetanus patient who did not received anticoagulation therapy. The possibility of IPH as a complication of tetanus should be considered before and during the administration of anticoagulation therapy.

Stroke Prevention in Patients with Atrial Fibrillation in Real Clinical Practice, Emphasis on Efficacy and Safety of Anticoagulant Therapy

Aim To evaluate frequency of administration of anticoagulant therapy (ACT) for atrial fibrillation and to study the effect of chronic antithrombotic therapy (ATT) on kidney function.Material and methods Due to a high medical and social significance of AF, much attention is presently paid to appropriate administration of ACT for AF in clinical practice. The study retrospectively analyzed 776 case reports of hospitalized patients with AF. The effect of chronic ATT on kidney function was studied in 70 patients who were rehospitalized, including 25 patients treated with warfarin, 25 patients treated with direct oral anticoagulants (DOAC), and 20 patients treated with acetylsalicylic acid (ASA).Results In January 2014, at the prehospital stage, 74.3 % of patients did not receive ATT, 14.7 % of patients received antiplatelet therapy, and only 11 % received anticoagulants. In the hospital in January 2014, ACTs were administered to 74.3 % of patients (warfarin, 58.6 %; DOAC, 15.7 %), 20.6 % of patients received antiplatelet drugs, and 5.1 % of patients were discharged without ATT. In January 2019, the number of patients receiving ACT at the prehospital stage increased to 58.1 % (warfarin, 13.8 %; DOAC, 44.3 %); 12 % of patients received antiplatelet drugs; and 29.9 % of patients did not receive ATT. The number of patients treated with warfarin and DOAC in the hospital increased to 14.8 % and 70.6 % (rivaroxaban, 33.4 %; apixaban, 25.5 %, and dabigatran, 11.7 %), respectively. The number of patients taking antiplatelet drugs decreased to 3.7 %, and the number of patients without ATT decreased to 10.9 %. There were no statistically significant differences in glomerular filtration rate (GFR) between these three groups at baseline. Only in the warfarin treatment group, GFR was significantly decreased from baseline during the follow-up period. Comparison of GFR in three study groups at the finale stage of the study showed significant differences between mean GFRs in the warfarin treatment group and the DOAC treatment group and between the warfarin treatment group and the ASA treatment group.Conclusion Among the prescribed and taken anticoagulants, DOACs are presently in the first place. Among DOACs, the most frequently prescribed drug is rivaroxaban. GFR decreases with the DOAC treatment slower than with the warfarin treatment. Despite the slower decrease in GFR with the ASA treatment compared to warfarin, ASA is not indicated for prevention of stroke in AF due to its low efficacy.

Catheter-Related Staphylococcus aureus Bacteremia and Septic Thrombosis: The Role of Anticoagulation Therapy and Duration of Intravenous Antibiotic Therapy.

BackgroundCatheter-related septic thrombosis is suspected in patients with persistent central line–associated bloodstream infection (CLABSI) after 72 hours of appropriate antimicrobial therapy. The clinical diagnosis and management of this entity can be challenging as limited data are available. We retrospectively studied the clinical characteristics of patients with Staphylococcus aureus catheter-related septic thrombosis and the outcomes related to different management strategies.MethodsThis retrospective study included patients with CLABSI due to S. aureus who had concomitant radiographic evidence of catheter site thrombosis treated at our institution between the years 2005 and 2016. We collected data pertaining to patients’ medical history, clinical presentation, management, and outcome within 3 months of bacteremia onset.ResultsA total of 128 patients were included. We found no significant difference in overall outcome between patients who had deep vs superficial thrombosis. Patients with superficial thrombosis were found to have a higher rate of pulmonary complications (25% vs 6%; P = .01) compared with those with deep thrombosis. Patients who received less than 28 days of intravascular antibiotic therapy had higher all-cause mortality (31 vs 5%; P = .001). A multivariate logistic regression analysis identified 2 predictors of treatment failure: ICU admission during their illness (odds ratio [OR], 2.74; 95% confidence interval [CI], 1.08–6.99; P = .034) and not receiving anticoagulation therapy (OR, 0.24; 95% CI, 0.11–0.54; P < .001).ConclusionsOur findings suggest that the presence of S. aureus CLABSI in the setting of catheter-related thrombosis may warrant prolonged intravascular antimicrobial therapy and administration of anticoagulation therapy in critically ill cancer patients.

Radiologic Image of a Child with Leukemia Who Developed Sepsis and Fulminant Thrombosis during Induction Therapy

In a 5-year-old girl with acute lymphoblastic leukemia (ALL), febrile neutropenia occurred in the induction phase of chemotherapy. She was not using a central venous catheter. Despite empiric antibiotics, she developed tachypnea, bilateral rales, and disseminated intravascular coagulation (DIC). Viral, bacterial, and fungal investigations were unremarkable. Thorax and abdominal computed tomography showed bilateral consolidation areas in the lungs and multiple infarcts in the left lower lobe of the lungs, the liver, the spleen, the kidneys, and the intestines (Figure 1). Heparin infusion was started. No inherited prothrombotic defect could be shown; antiphospholipid antibodies were negative. She died of pulmonary failure. Figure 1 Thorax and abdominal computed tomography of the patient demonstrating bilateral areas of consolidation in the lung parenchyma and multiple infarcts in the left lower lobe of the lungs, in the liver, in the spleen, in the left upper lobe of the left and ... Sepsis secondary to an unknown pathogen is the most common cause of mortality and the overall risk of symptomatic thrombosis is 5.2% in ALL [1,2,3]. Despite a high incidence of central nervous system and upper venous system events, widespread thromboembolism seems to be rare [3,4]. Our patient had multiple acquired risk factors, such as leukemia, concurrent administration of Escherichia coli asparaginase and prednisone, infection, and DIC. After administration of anticoagulant therapy, patients usually show improvement, but in our patient we could not reduce the occlusive events. This case is a good reminder for hematologists that the onset of neutropenic fever may be very aggressive and thrombotic events may occur rapidly and may be fulminant in children with ALL.

Inferior vena cava filter misplacement in the right atrium and migration to the right ventricle followed by successful removal using the endovascular technique: A case report and review of the literature

Inferior vena cava filters are effective for preventing the passage of thrombi into the pulmonary arteries in patients with pulmonary embolism and deep vein thrombosis. These filters are indicated in patients with contraindications to anticoagulant therapy or in patients with recurrent acute pulmonary embolism despite the administration of anticoagulant therapy. However, the occurrence of filter-related complications, such as filter migration to the heart, has been increasing. Herein, we report a case of OptEase inferior vena cava filter misplacement in the right atrium. Although the filter migrated to the right ventricle, it was successfully removed and repositioned in the inferior vena cava using endovascular techniques. Unfortunately, moderate tricuspid regurgitation developed, due to the damage to the tricuspid valve that was caused by the procedure. We have also reviewed the relevant literature and discussed the possible strategies for managing cases of filter migration to the heart and preventing filter misplacement.

Perioperativna diseminovana intravaskularna koagulacija nakon hirurškog lečenja aneurizmatske bolesti trbušne aorte - prikaz bolesnika

Disseminated intravascular coagulation (DIC) represents a pathological activation of coagulation (blood clotting) mechanisms that happens in response to a variety of diseases. Diseases of the blood vessels, such as aorta aneurysmal disease, could also cause local activation of coagulation. We report a case of DIC in a patient after the surgery of abdominal aorta aneurysm. 64-year-old woman was admitted to the Clinic for vascular surgery for the diagnosis and surgical treatment of abdominal aorta aneurysm. Multidetector computed tomography (MDCT) angiography verified abdominal aorta aneurysm 5.2 cm in diameter with significant aortoiliac stenosis and thereby aneurysm resection with aortobifemoral reconstruction was indicated. The operation went uneventfully but after completed reconstruction and declamping thrombosis of both limbs of Y graft was verified. Immediate bilateral thrombectomy was performed with the blood being sent for detailed analysis that revealed the presence of DIC. Regular monitoring of hemostatic parameters (coagulation factors, platelet function and rotational thromboelastometry (ROTEM)) enabled timely substitution and administration of anticoagulant therapy during and after surgery. On the 9th postoperative day the patient was discharged in good general condition. Forty days after surgery, the patient feels good with lower limbs vascularization well preserved. Early recognition of disseminated intravascular coagulation during the surgery by attending vascular surgeon, in cooperation with transfusiology center, is of great importance for well-timed detection and treatment of DIC and preventing serious and potentially lethal hemorrhagic and thrombotic complications in these patients.

Anticoagulant therapy with dabigatran in elderly patients ≥80 years of age with atrial fibrillation

Atrial fibrillation is a potent risk factor for stroke, and the administration of anticoagulant therapy is important for preventing thromboembolism. Dabigatran is the first new oral anticoagulant developed as an alternative to warfarin. However, serious major gastrointestinal bleeding events have been observed in elderly patients in post-market case reports. We therefore retrospectively investigated elderly cases of the use of anticoagulant therapy with dabigatran. Twenty-eight patients over 80 years of age were treated with anticoagulant therapy at our satellite hospital. Nine of the patients received dabigatran, and all others received warfarin. We evaluated the CHADS2 score, HAS-BLED score, renal function and incidence of adverse effects in nine patients treated with dabigatran. All of the nine patients received 220 mg/day of dabigatran, with no antiplatelet agents. Seven patients continued to receive dabigatran. One patient had an impaired renal function (Cr 1.55 mg/dl, Ccr 30 ml/min). However, the activated partial thromboplastin time (APTT) was not prolonged and neither major bleeding nor stroke were noted in seven patients. Although two patients were unable to continue dabigatran treatment due to APTT prolongation, no serious complications were observed during the administration of dabigatran. No serious adverse effects of dabigatran anticoagulant therapy were detected in our elderly patients. Although it is necessary to monitor the risk of bleeding, renal dysfunction, effects of drug combination and so on, some elderly patients with atrial fibrillation are good candidates for dabigatran treatment.