Catheter Thrombosis Research Articles

MP59-13 KIDNEY TRANSPLANT IN PATIENTS UNDER WARFARIN USE: DOES IT INCREASE THE RISKS? ANALYSIS OF OUTCOMES AND COMPLICATIONS

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery III (MP59)1 Apr 2020MP59-13 KIDNEY TRANSPLANT IN PATIENTS UNDER WARFARIN USE: DOES IT INCREASE THE RISKS? ANALYSIS OF OUTCOMES AND COMPLICATIONS Felipe Bernardes*, Matheus Siqueira, Gustavo Ebaid, Gustavo Messi, Renato Falci, Kleiton Yamacake, Rafael Locali, William Nahas, and Affonso Piovesan Felipe Bernardes*Felipe Bernardes* More articles by this author , Matheus SiqueiraMatheus Siqueira More articles by this author , Gustavo EbaidGustavo Ebaid More articles by this author , Gustavo MessiGustavo Messi More articles by this author , Renato FalciRenato Falci More articles by this author , Kleiton YamacakeKleiton Yamacake More articles by this author , Rafael LocaliRafael Locali More articles by this author , William NahasWilliam Nahas More articles by this author , and Affonso PiovesanAffonso Piovesan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000928.013AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Kidney disease (CKD) are known to increase the risk of venous thromboembolism. Also, the prevalence of atrial fibrillation (AF) is at least 10-fold higher than in the general population. Warfarin is the most common oral anticoagulant drug used to prophylactic therapy (OAT) in these patients. When CKD patients enter a Kidney transplant (KT) waiting list, they often remain on OAT. This implies the use of reversal agents at the time of Kidney transplant surgery specially with deceased donors. In this study, we aim to determine the outcomes and complications of KT in patients using OAT at the time of surgery. METHODS: From January 2009 to September 2019 2403 kidney transplants were done in our institution. There were 15 patients with current OAT use at the time of the procedure. We reviewed each patient record to determine OAT indication, type of anticoagulant in use, INR based on prothrombin time (PT) test prior to surgery, reversal drugs employed, concomitant use of Antiplatelets drugs, and need to reintroduction of OAT after KT. Surgical complications as well as long term graft function (estimated by MDRD and creatinine) were also investigated. RESULTS: From the 15 patients, 8 were male (53,3%) and 13 (86,7%) received kidney from deceased donors. Mean age was 54,6±11,0 years. Risk factors for thrombosis were the indication for ACO in 9 (60%) including arteriovenous fistula or hemodialysis catheter thrombosis and previous graft loss due to thrombotic event. In the remaining 6 (40%) OAT indication was AF. Eight patients (53,3%) were in concomitant use of Antiplatelets. Median INR in admission test was 2,2±1,0. On 12 patients (80%) the reversion therapy was vitamin K and fresh frozen plasma. The remaining 3 (20%) had INR < 1,5, dismissing treatment. Surgical excessive bleeding requiring transfusion were observed in 7 (46,7%) patients, and there were 02 deaths related to these complications. Re-introduction of OAT was necessary in 8 (53,3%) individuals. There was no statistical difference between long term renal graft function, with a median MDRD of 57,55 and creatinine of 1,6 after 5 years. CONCLUSIONS: Oral anticoagulants use adds surgical risks for bleeding complications and death in kidney transplant recipients, independently of anticoagulant reversal therapy. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e885-e886 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Felipe Bernardes* More articles by this author Matheus Siqueira More articles by this author Gustavo Ebaid More articles by this author Gustavo Messi More articles by this author Renato Falci More articles by this author Kleiton Yamacake More articles by this author Rafael Locali More articles by this author William Nahas More articles by this author Affonso Piovesan More articles by this author Expand All Advertisement PDF downloadLoading ...

The Effect of Anticoagulation on Bleeding and Thrombotic Events during Extracorporeal Membrane Oxygenation Support for Postcardiotomy Shock

Postcardiotomy shock patients supported with venoarterial extracorporeal membrane oxygenation (VA ECMO) are at high-risk for thrombotic and bleeding complications. No standardized anticoagulation guideline exists for these complex patients. We investigated the incidence of bleeding and thrombotic complications and their relation to anticoagulation therapy during VA ECMO in postcardiotomy shock patients. Between December 2007 and June 2018, VA ECMO was used to support 150 patients with postcardiotomy shock at our hospital. We conducted a retrospective review of this cohort. Bleeding events were defined as bleeding requiring transfusion or re-intervention occurring during VA ECMO support. Thrombotic events included circuit thrombosis, venous or arterial system thrombosis, intracardiac thrombus, and vascular catheter thrombosis. Logistic regression was performed to determine predictors of bleeding and thrombotic events. The median patient age was 65 years (interquartile range [IQR] 55-73). The median duration of VA ECMO support was 4.65 days (IQR 2.75-8.00). 116 patients (77%) were anticoagulated with heparin. The median length from initiation of VA ECMO to anticoagulation was 27 hours (IQR 10-59). The median activated partial thromboplastin time (aPTT) for the duration of support was 43 seconds (IQR 37-50). Bleeding occurred in 42 patients (28%), of which 32 received heparin. Thrombosis occurred in 32 patients (21%), of which 30 received heparin. Both bleeding and thrombosis occurred in 10 patients (6%). The average aPTT in those with bleeding did not differ from those without bleeding (50 vs. 51s, p = 0.719). The average aPTT in those with thrombosis was less than in those without thrombosis (45 vs. 52s, p = 0.047). Multivariable logistic regression demonstrated that bleeding complications were associated with increased length of support (p = 0.005) and female sex (p = 0.004), while thrombotic events were associated with male sex (p = 0.03), history of atrial fibrillation (p = 0.05), and history of hypertension (p = 0.01). Bleeding and thrombotic events are common complications during VA ECMO support for postcarditomy shock. aPTT values during VA ECMO may not adequately reflect the risk of bleeding but may better reflect the risk of thrombosis.

Echocardiographic and Angiographic Guided Removal of a Fractured Central Venous Access Port Using Snare Loop

: Central venous access is commonly performed in the care of critically ill patients, for administration of repeated drug treatments. This routine procedure has multiple complications such as catheter malposition, migration, obstruction, infection, thrombosis and catheter fraction. We must recognize, consider and be able to manage these complications. We report a successful endovascular technique using a snare for retrieving broken venous port in a 36-year-old female.

Central Venous Catheter Thrombosis in Cancer: A Multi-Centre Retrospective Study Investigating Risk Factors and Contemporary Trends in Management.

Objectives:Central venous access is needed to facilitate chemotherapy for many cancer patients. Central venous catheter-related thrombosis (CVCT) is a major complication that can cause significant morbidity and mortality. We sought to explore the rate of CVCT in a general cancer population in Australia and to identify factors associated with increased risk of thrombosis.Design:This is a multi-centre retrospective cohort study.Setting and participants:We analysed key patient, treatment, and cancer-related factors for 317 patients with cancer and central venous catheters inserted for systemic therapy.Main outcome measures:Symptomatic CVCT confirmed with imaging and management of patients with CVCT.Results:A total of 402 cases of central line insertion were analysed. Central venous catheter-related thrombosis occurred in 24 patients (6.0%). Having a peripherally inserted central catheter (PICC; HR = 3.78, 95% CI = 1.28-11.19, P = .02) compared with an implantable port and a body mass index of ⩾25.0 kg/m2 (HR = 3.60, 95% CI = 1.31-9.85, P = .01) were independently associated with increased risk of thrombosis. Central venous catheter-related thrombosis was managed mostly with removal of the catheter (19 of 24 cases) and anticoagulation, including direct-acting oral anticoagulants in 5 patients.Conclusions:This work explored rates of CVCT in a general cancer population, observing increased rates in those with PICCs or increased body mass index.

Long-term results of the DelIVery for Pulmonary Arterial Hypertension trial.

BackgroundThe DelIVery for Pulmonary Arterial Hypertension clinical trial was a multi-center, prospective, single arm, Investigational Device Exemption study utilizing a fully implantable, programmable intravascular delivery system consisting of a pump and a catheter for intravenous treprostinil. The study met its primary endpoint and demonstrated that the intravascular delivery system significantly reduced catheter related complications at 22,000 subject-days of follow-up compared with a predefined objective performance criterion. Here we summarize the results obtained during a 6.4-year follow-up period.MethodsThroughout study follow-up, participants had clinic visits and medication refills at least every 12 weeks (dependent on the subjects’ dose). All adverse events and intravascular delivery system complications were evaluated and recorded.ResultsSixty pulmonary arterial hypertension subjects were followed post device implantation for approximately 282 patient-years (range 87 days to 6.4 years). Of the 60 subjects, 14 died (1 related to intravascular delivery system pump failure), 2 withdrew after lung transplants, and 2 withdrew due to pump pocket infection. No catheter-related bloodstream infections, catheter thrombosis or occlusions, or catheter kinks occurred through 282 patient-years. Two participants had adverse events of abdominal pain, rash, due to subcutaneous treprostinil “leaks” after one catheter puncture and one catheter laceration during pump refill and replacement, respectively. Eight pump failure events occurred: seven pump motor stalls and one early replacement (faulty battery).ConclusionDelivery of treprostinil with an intravascular delivery system is a safe alternative to an external delivery system, while providing enhanced life experiences. To preserve the risk–benefit ratio, treatment at specialized pulmonary arterial hypertension centers is recommended until training is disseminated at other sites.

The effect of applying normal saline as sealing solution for umbilical venous catheter in VLBW premature infant

Objective To explore the effect of applying normal saline as sealing solution for umbilical venous catheter in very low birth weight (VLBW) premature infant. Methods Premature infants with VLBW were selected for umbilical vein catheterization, including 76 cases with central umbilical vein catheterization (UICC), 26 cases with simple umbilical vein catheterization (UVC), and 51 cases with central peripheral vein catheterization (PICC). All children were sealed with positive pressure pulse of 0.9% normal saline after infusion.The rate of catheter patency, incidence of thrombosis, infection rate, unplanned extubation rate and blood return rate within 7 days were observed. Results Catheter patency rate of UICC group、UVC group and PICC group was 100%, 96.15%、98.04%, thrombus incidence was 2.63%, 3.85%, 1.96%, infection rate was 3.95%, 0%, 3.92%, unplanned extubation rate was 10.53%, 38.46%, 7.84%, and blood return rate within 7 days was 61.84%, 3.85%, 88.24%.There was no statistical difference in the rate of catheter patency, thrombosis and infection rate among the three groups.There was no statistically significant difference in unplanned extubation rate between the UICC group and the PICC group, and there was statistically significant difference in blood return rate within 7 days (P<0.001). Conclusions As a catheter entrapment and sealing solution for very low birth weight premature infants, 0.9%normal saline can effectively maintain the pipeline patency and prevent catheter-related complications, especially in the UICC, which is more in line with the physiological characteristics of very low birth weight premature infants, and is worthy of clinical application. Key words: Premature infant; VLBWI; Umbilical vein; Central vein; Sealing solution; 0.9% normal saline

Trisodium citrate 4% versus heparin as a catheter lock for non-tunneled hemodialysis catheters in critically ill patients: a multicenter, randomized clinical trial

BackgroundNon-tunneled hemodialysis catheters are currently used for critically ill patients with acute kidney injury requiring extracorporeal renal replacement therapy. Strategies to prevent catheter dysfunction and infection with catheter locks remain controversial.MethodsIn a multicenter, randomized, controlled, double-blind trial, we compared two strategies for catheter locking of non-tunneled hemodialysis catheters, namely trisodium citrate at 4% (intervention group) versus unfractionated heparin (control group), in patients aged 18 years or older admitted to the intensive care unit and in whom a first non-tunneled hemodialysis catheter was to be inserted by the jugular or femoral vein. The primary endpoint was length of event-free survival of the first non-tunneled hemodialysis catheter. Secondary endpoints were: rate of fibrinolysis, incidence of catheter dysfunction and incidence of catheter-related bloodstream infection (CRBSI), all per 1000 catheter-days; number of hemorrhagic events requiring transfusion, length of stay in intensive care and in hospital; 28-day mortality.ResultsOverall, 396 randomized patients completed the trial: 199 in the citrate group and 197 in the heparin group. There was no significant difference in baseline characteristics between groups. The duration of event-free survival of the first non-tunneled hemodialysis catheter was not significantly different between groups: 7 days (IQR 3–10) in the citrate group and 5 days (IQR 3–11) in the heparin group (p = 0.51). Rates of catheter thrombosis, CRBSI, and adverse events were not statistically different between groups.ConclusionsIn critically ill patients, there was no significant difference in the duration of event-free survival of the first non-tunneled hemodialysis catheter between trisodium citrate 4% and heparin as a locking solution. Catheter thrombosis, catheter-related infection, and adverse events were not statistically different between the two groups.Trial registration Registered with Clinicaltrials.gov under the number NCT01962116. Registered 14 October 2013.

MON-132 PERCUTANEOUS TRANSHEPATIC TUNNELLED CATHETER FOR HAEMODIALYSIS: A SINGLE CENTRE EXPERIENCE

Obtaining vascular access for dialysis can be challenging in long-term haemodialysis patients who have exhausted all traditional access sites as a result of multiple catheter placements. Transhepatic dialysis catheter insertion is potentially life-saving for those with access failure. This study aims at evaluating the functionality and safety of transhepatic venous catheters in haemodialysis patients. Eight patients (3 male and 5 female, aged 59+/-17 years ) had transhepatic tunnelled dialysis catheters inserted in our haemodialysis unit in the past 3 years. The insertion method, type of catheter use, functional duration of catheters, maximum blood flow rate achieved, catheter complications and reasons for catheter removal were evaluated retrospectively. A total of eleven transhepatic catheters were placed in eight patients between January 2016 and November 2018. All the patients were on long term dialysis, with a mean dialysis vintage of 160 months. Most patients started with peritoneal dialysis, and switched to haemodialysis after peritoneal failure. The average heamodialysis duration was 85 months (range 14-144 months). Nine catheters were placed successfully (9/11, 82% technical success). Catheter insertion failed due to development of subphenic haematoma in 1 patient and the negotiation of the catheter into the proper venous position was unsuccessful in the other. One catheter was placed under general anaesthesia while the rest were done under local anaesthesia. RetrO® Long-Term Hemodialysis Catheter (BARD Access Systems) was used in 10 out of 11 of the procedures, and Permcath™ (Medtronic) was used in 1 case. Seven of the 9 functional catheters were placed in the portal vein while the remaining 2 were placed in the hepatic vein. The functional duration of transhepatic catheters ranges from 32 to 551 days, with a mean of 298 days. Of the 9 catheters, 2 were still in use at the end of the study (2/9, 22.2%). One patient died with a functional catheter. Six of the catheters were removed(6/9, 66.6%) . Arteriovenous fistular was created in 1 patient, while 3 catheters were removed due to catheter thrombosis (3/9, 33.3%). Two patients were noted to have catheter dislodgement into the pleural cavity (2/9, 22.2%), both presented with shock and haemothorax. Poor blood flow was the most common complication during the use of transhepatic catheters. Catheter revision was required in 2 cases. The maximum blood flow rate achieved for each catheter ranged from 150ml/minute to 250ml/minute, with a mean rate of 186ml/minute. The maximum blood flow rate was below 200ml/minute in 4 of the catheters (4/9,44.4%). Bleeding at the catheter site necessitating hospital admission occurred in 3 cases (3/9, 33.3%), catheter exit site infection occurred in 2 (2/9, 22.2%), but there were no catheter related sepsis. For patients who have exhausted access options for dialysis, transhepatic catheter placement is an alternative with potentially good long-term functionality. However, limitations in blood flow rate, and the high thrombosis rate with the need for high level of maintenance to preserve patency should be noted. Furthermore, physicians need to be cautious about potentially life-threatening complications such as catheter dislodgement.

Complications Associated with Permanent Internal Jugular Hemodialysis Catheter: A Retrospective Study.

IntroductionA significant increase in patients with end-stage renal disease has been observed currently in our community. Kidney transplantation is the most promising cure but the problem is that large numbers of people are not good candidates for transplantation. Hemodialysis is the next appropriate medication for such patients and for patients with end-stage renal disease, who have no chance for transplantation. Morbidity and mortality are the consequences of vascular access complications. Local data related to the complication rate of permanent hemodialysis catheters is not available. The current study examines the complication rate in people due to permanent intrajugular hemodialysis catheterization.Materials and methodsThe study has been conducted in Dr Ziauddin University Hospital, Karachi. The dataset consists of 212 patients who had gone through jugular catheterizations for hemodialysis at this hospital from the year 2014 to the year 2015. A descriptive method has been chosen for obtaining appropriate results. Complications have also been categorized as early or late.ResultsComplications have been detected in around 24% of the patients from the dataset. Among these complications, infection has the highest percentage (around 13%) while 4% percent of patients have a failed puncture. The others have venous thrombosis, catheter thrombosis, hematoma, wrong canulation, and hemothorax and pneumothorax problems.ConclusionThe study concludes that the placement of a permanent hemodialysis catheter in the internal jugular vein has a low complication rate. In addition, the method is safe and easy. So, it can be said that the internal jugular vein is a reliable and preferred route for hemodialysis catheterization.

Comparing Incidence of Thrombosis in PICC and Midlines and Evaluating the Role of Anticoagulation, Site of Insertion, and Risk Factors

HighlightsNew practice models are in demand for prevention and reduction in rates of catheter thrombosis that can be devastating to the health care system and patients Risk factors for catheter thrombosis were analyzed retrospectively for their impact Site of insertion and overall use of anticoagulation at the time of catheter placement did not show any significant impact on incidence of thrombosis Several variables (i.e., triple lumen, critically ill) were used to create a clinical prediction score model

A comparison of heparinised and non-heparinised normal saline solutions for maintaining the patency of arterial pressure measurement cannulae after heart surgery

BackgroundHeparinized solution (HS) use for the maintenance of arterial cannulas has been associated with coagulation disorders and has not been conclusively shown to confer additional benefits over normal saline (NS) alone. We tested the hypothesis that in adult patients admitted to the cardiac ICU (T0) after cardiac surgery, HS arterial cannulas might be independently associated with increased heparin-induced coagulation disorders and might not be superior to NS arterial cannulas in reducing arterial cannula occlusion.MethodsIn this cohort study, 170 patients who received NS arterial cannulas during the period from T0 to ICU discharge were included in this study from June 1, 2017, to May 1, 2018 (NS group). There were 2930 patients who used HS (2.5 U/ml) arterial cannulas from January 1, 2015, to December 31, 2016 (heparin group). To address indicated biases, we derived a propensity score that predicted the functions of NS and HS in the patency of arterial cannulas.ResultsThere were 296 patients (148 in the NS group and 148 in the heparin group) with similar risk profiles in the propensity-score matched cohorts. In the propensity-matched patients, the duration of arterial cannulas (P = 0.4) and arterial cannula occlusion (P = 0.5) showed no differences between the NS and heparin groups. However, the heparin group had a significantly increased activated clotting time (P < 0.05), activated partial thromboplastin time (P = 0.01) and allogeneic red blood cell utilization (3.4% vs 10.8%, P < 0.05). Compared with the NS group, the heparin group had more drainage from chest tubes from T0 to T48 (10.6 ± 9.4 ml/kg vs 13.0 ± 7.22 ml/kg, P < 0.05) and had more allogeneic red blood cells transfused (0.1 ± 0.4 U vs 0.4 ± 1.1 U, P < 0.05).ConclusionBased on the results of our study, the addition of heparin to normal saline for flushing arterial pressure monitoring cannulae did not reduce the incidence of catheter thrombosis and result in a very small but statically significant in increase in activated clotting time and activated partial thromboplastin time.

Is home parenteral nutrition safe for cancer patients? Positive effects and potential catheter-related complications: A systematic review.

Total Parenteral Nutrition began to be applied frequently in the houses of patients starting from the 1990s and is stated in literature as Home Parenteral Nutrition (HPN). The purpose of this review is to answer the question of whether or not HPN is safe for cancer patients. Searches were conducted in Cochrane, CINAHL, PubMed, Springer, Google Scholar, and the Web of Science databases. The 1,949 articles were accessed in the total, and 20 articles have been included in the review. In the studies being evaluated, it can be determined that HPN has influenced the quality of life, performance status, and the nutrition level of cancer patients positively. Most frequently seen complications were infections relating to the catheter, the mechanical obstruction in the catheter and venous thrombosis. For each 1,000days with HPN or a catheter, infections in the interval of 0.05 and 3.08, mechanical problems in the interval of 0.07 and 2.13, and thrombosis in the interval of 0.05 and 0.20 were determined. While HPN influenced quality of life, nutrition, and the personal performance of cancer patients positively, the rate of complications is at a level that can be managed at home.

Thrombosis of the Superior Vena Cava Surrounding Central Venous Catheter in a Patient with Superior Vena Cava Syndrome

Thrombosis of the Superior Vena Cava Surrounding Central Venous Catheter in a Patient with Superior Vena Cava Syndrome

Malignite Sebebiyle Kalıcı Port Kateter Takılan Hastalarda Kanser Tiplerine göre Klinik Takip ve Komplikasyonların Karşılaştırılması

Aim: In patients diagnosed with cancer, port catheter insertion is of critical importance for the appropriate delivery of the treatment and patient comfort. Aim of this study is to compare the patients placed subcutaneous port catheter in terms of the complications and the port remaining open based on cancer types.Material and Methods: A total of 530 patients who had port catheter insertion in our clinic for chemotherapy between January 2011 and December 2017 were included into the study. Of the cases, 234 (44.1%) were female and 296 (55.9%) were male; and the mean age was 57.90±10.18 years. The port catheters were placed subcutaneously under vascular ultrasonography and the position of the catheter was checked using fluoroscopy. Patients underwent physical examination to check for hemorrhage or hematoma, and underwent chest x-ray to check for pneumothorax or hemothorax. Patients were called in for checkup for wound-site infection and port thrombosis on the postoperative 10th and 30th days.Results: The majority of the patients who had port insertion were being followed up for gastrointestinal malignancies. Of the patients, 224 (42.2%) had port catheter insertion due to colon cancer, 68 (12.8%) due to breast cancer, and 111 (20.9%) due to gastric cancer. Frequency of catheter thrombosis was statistically higher in cases with colon and breast cancer. Wound site infection was observed more frequently in hematological malignancies.Conclusion: We suggest that, after port insertion, these complications can be reduced by using prophylactic anticoagulants for long-term port use in cases with breast and colon cancer, and by continuing empirical antibiotic treatment against endemic pathogens in cases with hematological cancers.

Unfractionated Heparin with Sequential Enoxaparin in Patients with Complex Coronary Artery Lesions during Percutaneous Coronary Intervention.

Background:Unfractionated heparin (UFH), despite its limitations, has been used as the primary anticoagulant alternative during the percutaneous coronary intervention (PCI). Some studies indicated that intravenous enoxaparin could be an effective and safe option. Our team used enoxaparin alone at one time according to the guidelines (Class IIA) and found a little catheter thrombosis during PCI. We recommend a new anticoagulation strategy using enoxaparin in combination with UFH. Enoxaparin has a more predictable anticoagulant response with no need of repeatedly monitoring anticoagulation during PCI. This retrospective study aimed to evaluate the efficacy and safety of using enoxaparin in combination with UFH in PCI patients with complex coronary artery disease.Methods:Between January 2015 and April 2017, 600 PCI patients who received intravenous UFH at an initial dose of 3000 U plus intravenous enoxaparin at a dose of 0.75 mg/kg (observation group) and 600 PCI patients who received UFH at a dose of 100 U/kg (control group) were consecutively included in this retrospective study. The endpoints were postoperative 48-h thrombolysis in myocardial infarction (TIMI) bleeding and transfusion and 30-day and 1-year major adverse cardio-cerebrovascular events (MACCE).Results:Baseline clinical, angiographic, and procedural characteristics were similar between groups, except there was less stent implantation per patient in the observation group (2.13 vs. 2.25 in the control group, P = 0.002). TIMI bleeding (3.3% vs. 4.7%) showed no significant difference between the observation group and control group. During the 30-day follow-up, the rate of MACCE was 0.9% in the observation group and 1.5% in the control group. There was no significant difference in the rates of MACCE, death, myocardial infarction, target vessel revascularization, cerebrovascular event, and angina within 30 days and 1 year after PCI between groups as well as in the subgroup analysis of transfemoral approach.Conclusions:UFH with sequential enoxaparin has similar anticoagulant effect and safety as UFH in PCI of complex coronary artery disease.

Brisk Upper Gastrointestinal Bleeding From Isolated Proximal Esophageal Varices

GI bleeding from isolated proximal esophageal varices, known as downhill varices, is a rare phenomenon comprising about 0.1% of all esophageal variceal bleeding. Superior vena cava (SVC) obstruction can impair systemic venous return and lead to the development of proximal esophageal collateralization resulting in varices. While most cases of downhill varices occur due to malignant SVC obstruction, benign causes have been reported. We describe an unusual case of benign high-grade SVC obstruction resulting in brisk downhill variceal bleeding. A 34 year-old woman with systemic lupus erythematosus complicated by ESRD requiring hemodialysis presented with large-volume hematemesis and melena. The patient had a similar presentation 16 months prior and had undergone EGD showing an actively bleeding Mallory Weiss tear and prominent proximal esophageal veins. Physical exam was notable for multiple tortuous and dilated superficial veins throughout abdomen. Urgent EGD was performed revealing grade II esophageal varices isolated to the proximal third of the esophagus with a fibrin plug. Band ligation was successfully performed. On further history, the patient revealed that over the last year she has had 9 right internal jugular central dialysis catheter placements due to repeated catheter thrombosis. A chest CT was obtained and demonstrated a high-grade short segment stenosis of the lower SVC with numerous prominent collateral vessels along the mediastinum and chest wall. The patient subsequently underwent angiography with balloon dilation and stent placement, with dramatic improvement in her physical exam findings of dilated abdominal wall veins within 24 hours. She has had no further GI bleeding. This is a rare case of hemodialysis catheter-associated SVC obstruction leading to proximal esophageal variceal bleeding in a young patient without mediastinal malignancy. Treatment for SVC obstruction varies based on the etiology and can include treating the primary malignancy, thrombolysis, balloon dilation and/or stent placement in cases of benign stenosis. Downhill variceal bleeding should be considered in patients presenting with upper GI bleeding with established or suspected SVC obstruction. Endoscopists must carefully examine the proximal esophagus and consider prophylactic intubation for airway protection. If isolated proximal esophageal varices are incidentally identified, contrast enhanced imaging of the chest is indicated to evaluate for SVC obstruction.

IMPLANTATION OF SUPERIOR VENA CAVA FILTERS

Abstract The purpose of this review is to evaluate the results of superior vena cava filters placement in order to prevent pulmonary embolism associated with upper extremities deep vein thrombosis. The central venous catheter, malignancy and lower extremities deep venous thrombosis are main risk factors of upper extremities deep venous thrombosis. The placement of the superior vena cava filter is a safe and effective method for preventing pulmonary embolism in patients with acute upper extremities deep vein thrombosis where therapeutic anticoagulation is contraindicated or appeared to be ineffective.

Ethanol lock is effective on reducing the incidence of tunneled catheter-related bloodstream infections in hemodialysis patients: a systematic review and meta-analysis.

The purpose of this meta-analysis is to evaluate the effect of ethanol lock on the incidence of catheter-related bloodstream infection (CRBSI) in patients with central venous catheters. RCTs comparing ethanol lock with another solution lock for prevention of CRBSI were obtained by searching databases of PubMed, Embase, Web of Science and Cochrane Central Register of clinical trials for eligible randomized controlled trials (inception to December 2017). Two researchers separately selected the RCTs and assessed their quality. Data on patient characteristics and ethanol protocols were collected. The primary outcome was the incidence of CRBSI, and the secondary outcomes were catheter colonization, exit infection and thrombosis. A total of 2575 patients with 3375 catheters from 7 eligible RCTs were included. Overall, ethanol lock significantly decreased the risk of CRBSI, with RR 0.54 (95% CI 0.38-0.78; I2 = 0%; p = 0.001); no obvious heterogeneity was observed in the fixed-effects model (I2 = 0%). Of note, subgroup analysis demonstrated that ethanol lock conferred significant benefit in studies with tunneled catheters (RR 0.46; 95% CI 0.30-0.72) but not in studies with untunneled catheters. Only two studies provided data regarding catheter colonization, and no significant difference was found (RR, 1.09; 95% CI, 0.87-1.38; I2 = 41%; p = 0.45). Moreover, pooled data did not show significant differences between ethanol and control groups with regard to the incidence of thrombosis (RR 1.05; 95% CI 0.91-1.22; I2 = 0%; p = 0.48). Our meta-analysis suggests that ethanol lock is effective on reducing the incidence of CRBSI in hemodialysis patients with tunneled central venous catheters.

Low-Dose Unfractionated Heparin with Sequential Enoxaparin in Patients with Diabetes Mellitus and Complex Coronary Artery Disease during Elective Percutaneous Coronary Intervention.

Background:Despite its limitations, unfractionated heparin (UFH) has been the standard anticoagulant used during percutaneous coronary intervention (PCI). This study compared the safety of low-dose UFH with sequential enoxaparin with that of UFH in patients with diabetes mellitus (DM) and complex coronary artery disease receiving elective PCI.Methods:In this retrospective study, 514 consecutive patients with atherosclerotic cardiovascular diseases and type 2 DM were admitted to the hospital and received selective PCI, from January 2013 to December 2015. All patients with PCI received low-dose UFH with enoxaparin (intraductal 50 U/kg UFH and 0.75 mg/kg enoxaparin, n = 254; UFH-Enox group) or UFH only (intraductal 100 U/kg UFH, n = 260; UFH group). The study endpoints were major adverse cardiac events (MACEs), namely death, myocardial infarction (MI), stroke, target-vessel immediate revascularization (TVR), and thrombolysis in MI (TIMI) major bleeding, within 30 days and 1 year after PCI. Any catheter thrombosis during the procedure was recorded.Results:Only one patient had an intraductal thrombus in the UFH group. At the 30-day follow-up, no MACE occurred in any group; seven and five cases of recurrent angina and/or rehospitalization were reported in the UFH-Enox and UFH groups, respectively; there was no significant difference between the two groups (χ2 = 0.11, P = 0.77). There was no TIMI major bleeding in the groups. With respect to the 1-year endpoint, two cases of recurrent MI and two of TVRs were reported in the UFH-Enox group, whereas in the UFH group, one case of recurrent MI and three of TVRs were reported; no significant difference existed between the two groups (χ2 = 0, P = 0.99). There were 30 and 25 recurrent angina and/or rehospitalizations in the UFH-Enox and UFH groups, respectively; there was no significant difference between the two groups (χ2 = 0.37, P = 0.57).Conclusion:In elective PCI, low-dose UFH with sequential enoxaparin has similar effects and safety to the UFH-only method.

Antimicrobial lock solutions for preventing catheter-related infections in haemodialysis.

Patients undergoing haemodialysis (HD) through a central venous catheter (CVC) are exposed to several risks, being a catheter-related infection (CRI) and a CVC lumen thrombosis among the most serious. Standard of care regarding CVCs includes their sealing with heparin lock solutions to prevent catheter lumen thrombosis. Other lock solutions to prevent CRI, such as antimicrobial lock solutions, have proven useful with antibiotics solutions, but not as yet for non-antibiotic antimicrobial solutions. Furthermore, it is uncertain if these solutions have a negative effect on thrombosis incidence. To assess the efficacy and safety of antimicrobial (antibiotic, non-antibiotic, or both) catheter lock solutions for preventing CRI in participants undergoing HD with a CVC. We searched the Cochrane Kidney and Transplant Specialised Register up to 18 December 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. We included all randomised or quasi-randomised control trials (RCTs) comparing antimicrobial (antibiotic and non-antibiotic) lock solutions to standard lock solutions, in participants using a CVC for HD, without language restriction. Two authors independently assessed studies for eligibility, and two additional authors assessed for risk of bias and extracted data. We expressed results as rate ratios (RR) per 1000 catheter-days or 1000 dialysis sessions with 95% confidence intervals (CI). Statistical analyses were performed using the random-effects model. Thirty-nine studies, enrolling 4216 participants, were included in this review, however only 30 studies, involving 3392 participants, contained enough data to be meta-analysed. Risk of bias was low or unclear for most domains in the majority of the included studies.Studies compared antimicrobial lock solutions (antibiotic and non-antibiotic) to standard sealing solutions (usually heparin) of the CVC for HD. Fifteen studies used antibiotic lock solutions, 21 used non-antibiotic antimicrobial lock solutions, and 4 used both (antibiotic and non-antibiotic) lock solutions. Studies reported the incidence of CRI, catheter thrombosis, or both.Antimicrobial lock solutions probably reduces CRI per 1000 catheter-days (27 studies: RR 0.38, 95% CI 0.27 to 0.53; I2 = 54%; low certainty evidence), however antimicrobial lock solutions probably makes little or no difference to the risk of thrombosis per 1000 catheter days (14 studies: RR 0.79, 95% CI 0.52 to 1.22; I2 = 83%; very low certainty evidence). Subgroup analysis of antibiotic and the combination of both lock solutions showed that both probably reduced CRI per 1000 catheter-days (13 studies: RR 0.30, 95% CI: 0.22 to 0.42; I2 = 47%) and risk of thrombosis per 1000 catheter-days (4 studies: RR 0.26, 95% CI: 0.14 to 0.49; I2 = 0%), respectively. Non-antibiotic antimicrobial lock solutions probably reduced CRI per 1000 catheter-days for tunnelled CVC (9 studies: RR 0.60, 95% CI 0.40 to 0.91) but probably made little or no difference with non-tunnelled CVC (4 studies: RR 0.93, 95% CI 0.48 to 1.81). Subgroup analyses showed that antibiotic (5 studies: RR 0.76, 95% CI 0.42 to 1.38), non-antibiotic (8 studies: RR 0.85, 95% CI 0.44 to 1.66), and the combination of both lock solutions (3 studies: RR 0.63, 95% CI 0.22 to 1.81) made little or no difference to thrombosis per 1000 catheter-days compared to control lock solutions. Antibiotic antimicrobial and combined (antibiotic-non antibiotic) lock solutions decreased the incidence of CRI compared to control lock solutions, whereas non-antibiotic lock solutions reduce CRI only for tunnelled CVC. The effect on thrombosis incidence is uncertain for all antimicrobial lock solutions. Our confidence in the evidence is low and very low; therefore, better-designed studies are needed to confirm the efficacy and safety of antimicrobial lock solutions.