Complication Of Anticoagulant Therapy Research Articles

Discrepancies in Identification of Major Bleeding Events in Patients Taking Warfarin

To assess the level of agreement between one subjective definition of major bleeding (criteria A) and two objective definitions: the International Society on Thrombosis and Haemostasis ([ISTH] criteria B) and the Italian Study of Complications of Anticoagulant Therapy ([ISCOAT] criteria C). Retrospective cohort study. Four anticoagulation clinics at a university-affiliated medical center. One hundred twenty patients aged 21-96 years who were taking long-term warfarin therapy and experienced a nonminor bleeding event between July 1, 2001, and June 30, 2006. Bleeding events were evaluated using three definitions of major bleeding: criteria A-event was fatal or required hospitalization; criteria B-event was fatal, was symptomatic in a critical area or organ, caused a decrease in hemoglobin level of 2 g/dl or more, and/or led to transfusion of 2 or more units of whole blood or red blood cells; and criteria C-event met criteria B definition (but less inclusively identifies critical areas or organs) and/or necessitated surgical or angiographic intervention. One hundred thirty-eight bleeding events in the 120 patients met at least one of the definitions of major bleeding and thus were included in the analysis. Level of agreement among the definitions was determined by the kappa statistic. The level of agreement between criteria B and C was excellent; no discrepancies were found; however, the level of agreement between criteria A and criteria B or C was poor, with a kappa statistic value of -0.134 (95% confidence interval -0.196 to -0.071). Use of criteria A resulted in underreporting of 31 major bleeding events by excluding events that were managed on an outpatient basis. The discrepant event rates determined by using three different definitions of major bleeding underscore the need for implementation of a standardized objective definition. Use of a standardized definition in clinical trials to accurately predict and compare patient outcomes and in clinical practice as a marker for patient safety will increase quality of care and decrease total costs of care in patients treated with warfarin. We suggest implementation of the ISTH criteria in clinical practice as a method to standardize the reporting of major bleeding events.

Hemorrhagic cholecystitis as a complication of anticoagulant therapy: role of CT in its diagnosis

Hemorrhage within the gallbladder lumen is a rare but potentially fatal complication of acute cholecystitis. Concomitant anticoagulant therapy increases the chances of hemorrhage. In this case report we describe one such case which showed active extravasation of the contrast into the lumen of the gallbladder. Early diagnosis of this potentially fatal condition is important to facilitate urgent surgical treatment.

Syndrome occlusif et hémorragique révélant un hématome duodénal intramural iatrogène

An intramural hematoma of the duodenum was first reported in an article in the Lancet in 1838. At least, 90% of cases are caused by blunt abdominal trauma, typically accidents involving bicycles or motor vehicles. Intramural duodenal hematoma is a rare complication of anticoagulant therapy. It occurs in patients who receive excessive anticoagulation with warfarin or who have some other risk factor for bleeding. CT characteristics include circumferential wall thickening, intramural hyperdensity, luminal narrowing, and intestinal obstruction. Early diagnosis is crucial because most patients are treated nonoperatively with a good outcome.

Gigantic retroperitoneal hematoma as a complication of anticoagulation therapy with heparin in therapeutic doses: a case report

IntroductionSpontaneous retroperitoneal hemorrhage is a distinct clinical entity that can present as a rare life-threatening event characterized by sudden onset of bleeding into the retroperitoneal space, occurring in association with bleeding disorders, intratumoral bleeding, or ruptures of any retroperitoneal organ or aneurysm. The spontaneous form is the most infrequent retroperitoneal hemorrhage, causing significant morbidity and representing a diagnostic challenge.Case presentationWe report the case of a patient with coronary artery disease who presented with transient ischemic attack, in whom anticoagulant therapy with heparin precipitated a massive spontaneous atraumatic retroperitoneal hemorrhage (with international normalized ratio 2.4), which was treated conservatively.ConclusionDelay in diagnosis is potentially fatal and high clinical suspicion remains crucial. Finally, it is a matter of controversy whether retroperitoneal hematomas should be surgically evacuated or conservatively treated and the final decision should be made after taking into consideration patient's general condition and the possibility of permanent femoral or sciatic neuropathy due to compression syndrome.

Retropharyngeal Hematoma as a Complication of Anticoagulation Therapy

Reports in the literature of retropharyngeal hematoma as a complication of anticoagulation therapy are rare. When this complication does occur, it can become life-threatening if the airway is compromised. However, no consensus exists as to which approach--intubation, tracheotomy, or conservative therapy--is best for managing the airway in these cases. We report a case of retropharyngeal hematoma that occurred as a sequela to a trivial blunt trauma in a 48-year-old man who had been undergoing anticoagulation therapy with warfarin. The hematoma had caused airway obstruction, and the patient was hospitalized. He was treated conservatively, and the hematoma slowly resolved over the course of 2 weeks. On the basis of our experience and the findings of our literature review, we suggest that conservative management can be initiated for small nonexpanding hematomas that do not seriously compromise the airway. Securing the airway with intubation or tracheotomy should be reserved for patients who are in serious respiratory distress; the choice between intubation and tracheotomy should be made on an individual basis.

Transcatheter Arterial Embolization of Spontaneous Rectus Sheath Haematoma in a Chinese Woman

Spontaneous extraperitoneal haemorrhage is a rare but well-described complication of anticoagulation therapy. We report a case of spontaneous rectus sheath haematoma in a 69-year-old Chinese woman who had received low-molecular-weight heparin for pulmonary embolism. She presented with sudden onset of lower abdominal pain, hypotension and a tender lower abdominal mass after 1 week of anticoagulation therapy. Computed tomography revealed a huge right rectus sheath haematoma extending into the pelvis, and angiography demonstrated active contrast extravasation from the right inferior epigastric artery. Arterial embolization with Gelfoam was performed and succeeded in stopping the bleeding. Transcatheter arterial embolization can be an effective and safe modality to localize and treat the bleeder in spontaneous extraperitoneal haematoma for high-risk patients.

Clinical study on pneumoconiosis with pulmonary thromboembolism

To probe into the clinical features and the rescue of pneumoconiosis with pulmonary thromboembolism (PTE). 26 patients with pneumoconiosis and PTE, male 16, female 10, were collected from June 2002 to June 2006 and 42 patients only with pneumoconiosis served as control. Tissue plasminogen activator (t-PA), plasminogen activator inhibitor-1 (PAI-1), thrombomodulin (TM), plasma protein S, C (Ps, Pc), homocysteine (Hcy) were measured by the methods of ILISA, and antithrombin (AT-III) by chromo substrate method before and after the treatment of heparin. The average age of patients with pneumoconiosis and PTE was 66.0 +/- 11.9 years old. The number of patients with pneumoconiosis of degree 1, 2, 3 was 3, 16 and 7 respectively. After anticoagulant therapy of heparin, 23 were well improved, and 3 died of acute respiratory failure. Dyspnea, chest pain, hemoptysis, syncope were the conspicuous symptoms. The levels of D-Dimer (0.63 +/- 0.14 mg/L), TM (5.02 +/- 1.24 microg/L) were significantly higher than those of the control (P < 0.05), and significantly lower again after the treatment (P < 0.05). The level of AT-III (96.68 +/- 7.23%) was significantly lower than that of the control, and higher again after the treatment (P < 0.05). PTE is often developed in the elder patients with high degree of pneumoconiosis (> or = 2 degree). Clinical features are complicated and non-specific, with the high negative ratio of D-Dimer (7/26), high mortality and high complications of anticoagulant therapy.

Inferior Vena Cava Filters in the Management of Venous Thromboembolism

Inferior vena cava (IVC) filters, both retrievable and permanent, are indicated for the prevention of pulmonary embolism (PE) in patients contraindicated for anticoagulant therapy, in those with anticoagulant therapy complications, and perhaps for those with recurrent PE despite therapeutic anticoagulation. Because of the lack of randomized controlled trials (only 1 has been published), clinicians have little evidence-based information to assist them in determining proper use of IVC filters. The introduction of retrievable filters and the ease of insertion have stimulated increased use of these devices without strong evidence or follow-up to assess either efficacy or longer-term clinical outcomes. Current evidence-based guidelines recommend IVC filter insertion only in patients with proven venous thromboembolism and an absolute contraindication for anticoagulation.

Spontaneous intramural intestinal haematoma

An 83-year-old man presented with a 3-day history of progressive abdominal pain and vomiting. He had a 20year history of hypertension and atrial fibrillation andwas taking antihypertensive agents and warfarin. The physical examination showed diffuse abdominal tenderness without rigidity. The routine complete blood count, serum biochemistry profiles were unremarkable except for an increased C reactive protein and prolonged prothrombin time. A plain abdominal radiograph showed distended small bowel loops (Fig. 1). Computed tomography (CT) of the abdomen, without i.v. contrast, showed marked thickening of the wall of the upper jejunum (Fig. 2). The density of the thickened bowel wall ranged from 40 to 60 Hounsfield Units (HU), similar to the density of blood in the abdominal aorta. Anticoagulant-induced intramural intestinal haematomawas diagnosed. The patient received conservative treatment with i.v. fluids and was discharged after7 days.A follow-upabdominalCTscanshowed that the intramural intestinal haematoma had largely resolved (Fig. 3).Hehashadno recurrences and continues todowell. Spontaneous intramural intestinal haematoma is a rare complication of anticoagulant therapy. It is often not suspected clinically and the diagnosis is usually made after abdominal imaging or when exploratory laparotomy is carried out. The non-contrast CT appearance of spontaneous intramural intestinal haematoma was originally described by Plojoux et al. as a hyperdense bowel wall with density ranging from 50 to 80 HU, depending on the time interval between the onset of bleeding and the CT examination. The following CT characteristics should suggest the diagnosis: circumferential wall thickening, intramural hyperdensity, luminal narrowing and intestinal obstruction. In general, conservative therapy is the treatment of choice, whereas surgical intervention is indicated

Anticoagulant-Induced Intramural Hematoma of Small Bowel: Report of a Case

Intramural hematoma (IMH) of bowel is a rare complication of anticoagulant therapy, mainly with warfarin, with a reported incidence of 0.04%. In such therapy, the prothrombin time (PT) and activated partial thromboplastin time (aPTT) data are usually prolonged. The clinical presentations, such as abdominal pain and vomiting are nonspecific, and sometimes the IMH may be misdiagnosed as an acute abdomen requiring emergent or urgent surgical intervention. We present a case with a past history of mechanical aortic valve replacement, presenting to the emergency department manifestations of recurrent acute abdomen. Ileus of unknown cause was the impression in the first two visits, and finally IMH due to anticoagulation therapy was diagnosed by image studies and history taking. He was managed successfully by a conservative method. Also the literature with regard to this topic is reviewed.

Retroperitoneal hematoma compressing a single functioning kidney: an unusual cause of obstructive renal failure

We report a case of a retroperitoneal hematoma occurring in a patient under anticoagulation therapy for deep-venous thrombosis and presenting as an anuric acute renal failure. A coexisting polycythemia vera led to misdiagnosis that could have been life-threatening. A woman, known for polycythemia vera and a single functioning right kidney, was admitted with mild abdominal pain in a context of recent deep venous thrombosis under low-molecular weight heparin. Clinical examination revealed hepatomegaly associated with polycythemia vera. Biochemical evaluation disclosed an acute renal failure, and renal ultrasonography showed no dilation of the renal pelvis. Retroperitoneal hematoma resulted in shock, progressive anemia and obstructive renal failure, related to renal pelvic compression. A right renal indwelling catheter was introduced to restore urine flow after one hemodialysis session, and an inferior vena cava filter was placed because of anti-coagulation contra-indication. However, pulmonary embolism occurred, so that oral anticoagulants were introduced. The hematoma resorbed spontaneously, and a year after this episode, the patient is still alive and well. Retroperitoneal hematoma is a rare cause of obstructive acute renal failure and a life-threatening complication of anti-coagulation therapy.

Rectus sheath hematoma complicating low‐molecular weight heparin therapy

Rectus sheath hematoma (RSH) is an uncommon but serious bleeding complication of anticoagulant therapy that has received little attention in the literature. Two cases of RSH among recent admissions to an inpatient medicine service and four archival cases were reviewed. All six patients were on low-molecular weight heparin (LMWH) therapy. Five of the six patients had a creatinine clearance of 40 ml/min or less, and five also had cough. Two patients with the most serious outcome were aged 90 and 92 years. RSH complicating LMWH therapy appears to constitute a clinical syndrome consisting of sudden onset of abdominal pain in the setting of renal insufficiency, advanced age and abdominal straining (e.g. cough). Risk of RSH may be reduced in patients receiving LMWH by assessing renal function, monitoring heparin levels (e.g. when the creatinine clearance is 40 ml/min or less) and adjusting the dose accordingly; by avoidance of abdominal strain (e.g. by treating cough); and by attention to technique when the abdominal wall is used as the injection site. Patients of advanced age may be at particular risk for RSH.

SPONTANEOUS COLONIC HEMATOMA: ENDOSCOPIC APPEARANCE

Intramural colonic hematoma is a rare complication of anticoagulation therapy. We report a patient under therapy with acetylsalicylic acid, low‐molecular‐weight heparin and clopidogrel for unstable angina, who presented with massive lower gastrointestinal bleeding secondary to spontaneous intramural colonic hematoma, with unremarkable coagulation tests. Diagnosis was promptly made by colonoscopy, and the patient was successfully managed with a conservative approach, with complete resolution of symptoms after 7 days. This is the first report of spontaneous intramural colonic hematoma presumed to be related to acetylsalicylic acid, enoxaparin and clopidogrel.

Warfarin-induced skin necrosis after open heart surgery due to protein S and C deficiency

Warfarin-induced skin necrosis is the rare but potentially devastating complication of anticoagulant therapy and commonly occurs in previously undetected C- and S-protein deficient patients. Because routine preoperative examination does not include protein C and S level measurement, detection of these patients preoperatively is generally not possible, which increases the risk of occurrence of this important complication. In this report we present and discuss such a patient, who died from warfarin-induced skin necrosis after coronary artery bypass surgery.

Bilateral adrenal hemorrhage: An overlooked cause of hypotension

Bilateral adrenal hemorrhage resulting in acute adrenal insufficiency is a rare complication of anticoagulant therapy. We present the case of a patient who came to the Emergency Department with unsuspected adrenal insufficiency, followed by a second visit within 1 month with shock, to demonstrate the importance of early detection and treatment.

Hemorrhagic shock as a complication of anticoagulant therapy following the mitral valve replacement

This report describes a case of the hemorrhagic shock in a patient on the anticoagulant therapy supplementing implanted mechanical prosthetic heart valve replacing the mitral valve. The association between hemorrhagic shock, mechanical prosthetic heart valve and anticoagulant therapy is briefly discussed.

Massive Subchorionic Hematoma Associated With Enoxaparin

The use of low-molecular-weight heparins is increasing for the prevention of thromboembolism in pregnancy. Subchorionic hematoma as a complication of anticoagulation therapy is rarely reported. A persistent, massive subchorionic hematoma was diagnosed in a pregnant patient with atrial fibrillation and mitral stenosis. Enoxaparin was administered to maintain her trough anti-Xa level 0.5 units/mL or higher. The patient's peak anti-Xa levels never exceeded 1.05 units/mL. The patient underwent cesarean delivery at 34 6/7 weeks of gestation for preterm premature rupture of membranes. Subchorionic hematoma is a potentially serious complication that can occur in pregnant patients receiving enoxaparin for the prevention of thromboembolism.

Spinal Chronic Subdural Hematoma in Association With Anticoagulant Therapy

A case of spinal chronic subdural hematoma (SCSDH) in association with anticoagulant therapy was treated surgically. To clarify the etiopathogenesis, clinical presentation, and surgical outcomes of SCSDH. Intracranial chronic subdural hematoma is a well-recognized complication of anticoagulant therapy. However, SCSDH is very rare and its etiopathogenesis is uncertain. A 72-year-old man with SCSDH who had received anticoagulant therapy for atrial fibrillation complained of bilateral lower extremity pain, cramps, and gait disturbance. The patient underwent an operation for evacuation of the hematoma. Lower-extremity pain, cramps, and gait disturbance improved, and the patient was discharged 10 days after surgery. SCSDH should be included in the differential diagnosis of progressive spinal cord and nerve root compression in patients receiving anticoagulant therapy. Prompt diagnosis and early surgical decompression lead to a good outcome.

Upper airway obstruction by sublingual hematoma: a complication of anticoagulation therapy with acenocoumarol

Upper airway obstruction secondary to the use of oral anticoagulants has been reported. In most of the cases, it is produced by retropharyngeal and laryngeal hematomas. The sublingual space is an extremely rare site for bleeding, but this constitutes a life-threatening complication, it must be considered as an emergency situation, and the main priority is to secure patient's airway. We recommend immediate reversal of the anticoagulation therapy, preferably with fresh frozen plasma. The surgical drainage usually is not recommended. We present what is to our knowledge the 10th case reported of an airway obstruction due to sublingual hematoma after the administration of oral anticoagulants, and the third one due to the use of acenocoumarol.

Warfarin-Induced Skin Necrosis: A Case Report

Warfarin-induced skin necrosis is an unusual complication of anticoagulation therapy associated with high morbidity. A patient is presented who had protein C deficiency and in whom this complication developed twice within a short time as a result of delayed diagnosis. Early recognition of this syndrome has important implications in the treatment of such patients and may reduce the severity of complications.