Continuous Anticoagulant Therapy Research Articles

Is it safe to discontinue anticoagulant after surgical treatment of varicose vein disease, which caused pulmonary embolism?

Superficial vein thrombosis, which is mostly caused by lower extremity varicose vein disease, can be complicated by pulmonary embolism. At the same time, the optimal duration of anticoagulant therapy for pulmonary embolism originated from varicose vein thrombosis is still under debate. On the one hand, the presence of varicose veins is considered a small risk factor for the development of venous thromboembolic events, which persistence determines an increased risk of relapse and requires prolonged anticoagulant therapy. On the other hand, elimination of varicose veins is associated with reduced risk of subsequent venous thromboembolic events. The article describes a clinical case of recurrent pulmonary embolism after surgical treatment of varicose vein disease, which caused primary pulmonary embolism. A 45-year-old patient suffering from left lower extremity varicose vein disease for 5 years was admitted to the intensive care unit with suspected pulmonary embolism. The further examination revealed signs of thrombotic occlusion of the segmental and subsegmental branches of the pulmonary arteries bilaterally and the middle lobe branch of the right pulmonary artery, as well as signs of the right-sided heart overload. In this case, pulmonary embolism was found to originate from thrombosis of the trunk of the great saphenous vein ofthe left lower extremity with a proximal border at the level of the lower leg. No signs of deep vein involvement were detected. The parenteral anticoagulant therapy initiated in the hospital was followed by switching to therapeutic doses of rivaroxaban. The signs of recanalization of involved veins were identified after 6 months of treatment, and it was decided to perform endovenous laser coagulation of the trunk of the great saphenous vein combined with mini-phlebectomy of varicose tributaries on continuous oral anticoagulant therapy. The rivaroxaban therapy was completed a month after intervention. However, 7 days later the patient was diagnosed with repeated symptomatic pulmonary embolism, which originated from thrombosis of the left popliteal vein. It was recommended to resume anticoagulant therapy of indefinite duration. The article discusses the issues of optimal duration of treatment for pulmonary embolism originated from thrombosis of superficial varicose veins, as well as the possible timing of completion of anticoagulant therapy after the intervention.

BETWEEN SCYLLA AND CHARYBDIS: MULTIPLE LEFT ATRIAL THROMBI DESPITE ORAL ANTICOAGULATION AND ANTIPLATELET THERAPY IN A PATIENT CANDIDATE FOR LEFT ATRIAL APPENDAGE OCCLUSION

Abstract Introduction Left atrial (LA) thrombosis usually occurs in patients affected by atrial fibrillation (AF), generally involving the left atrial appendage (LAA). We present the unexpected echocardiographic finding of multiple LA thrombi despite an adequate antithrombotic strategy. Case Presentation A 76–year–old lady underwent transesophageal echocardiographic examination (TOE) to assess eligibility for percutaneous LAA occlusion (LAAO) procedure due to high bleeding risk. Her medical history included AF and a recent percutaneous coronary revascularization; therefore, her antithrombotic therapy included apixaban 2.5 mg bid and clopidogrel 75 mg od. The TOE showed LA structural and functional remodeling with spontaneous echo contrast and multiple thrombi involving the LAA (one [12 x 9 mm] overflowing the orifice and attached to the Coumadin Ridge and the second [12 x 7 mm] attached and arising from the tunnel of patent foramen ovale). Mitral valve stenosis was excluded (Fig.1). Due to TOE findings, the patient was not considered eligible for percutaneous LAAO. Due to the concomitant very high thromboembolic risk, despite the previous intracranial bleeding, we decided to stop apixaban and to start parenteral anticoagulation for 3 weeks with low–molecular weight heparin (100 UI/kg bid) followed by the switch to a vitamin k antagonist (VKA). We also prescribed a hematological evaluation to exclude a hypercoagulability disorder. Our patient’s daughter was a carrier of a mutation in both the methylenetetrahydrofolatereductase and Thrombin genes. A TOE after 30 days showed the persistence of LA thrombi, although with significantly reduced size and mobility (Fig.2). The follow–up was clinically uneventful. We suggested to continue anticoagulation therapy with VKA, and we planned a new TOE after 4 weeks. Discussion Although proper anticoagulation decreases cardioembolic risk in patients with AF, atrial thrombosis may occur due to LA remodeling, high CHA2DS2–VASc score and other factors, including hypercoagulability disorders. The presence of multiple LA thrombi represents a challenge for clinicians, especially in case of concomitant high thromboembolic and bleeding risk. However, the best treatment strategies for these extreme conditions are not defined, so far. Therefore, the therapeutic choice is often tailored to the single patient and based on the clinical judgment, bearing in mind that avoiding Charybdis means passing to close to Scylla and vice versa.

Incidence of Acute Thrombosis After Surgical Left Atrial Appendage Occlusion for Atrial Fibrillation

BackgroundThe clinical implications of acute phase thrombosis after surgical left atrial appendage (LAA) closure remain unclear. This study sought to determine the frequency, prognosis, and factors involved in thrombogenesis after surgical LAA occlusion. MethodsIn this study, data from patients who underwent 2 types of standalone surgical LAA closure (either resection or clipping) between July 2014 and March 2020 at a single center were analyzed. ResultsA total of 239 consecutive patients with atrial fibrillation underwent minimally invasive standalone surgical LAA occlusion (184 resection cases and 55 clipping cases). On postoperative day 2, electrocardiogram synchronized contrast-enhanced computed tomography (CT) was performed in 223 cases (93.3%), and echocardiography follow-up was performed in 16 cases when CT was contraindicated. Acute postoperative thrombus on the closed stump was detected in 35 cases (14.7%), of which 29 cases (15.8%) belonged to the resection group and 6 cases (10.9%) belonged to the clipping group. No significant difference was detected between the groups, and no significant predictors of acute-phase thrombosis were found. Thromboembolism occurred in 4 patients before postoperative imaging follow-up, and there was no evidence of thrombi in these patients on postoperative day 2 CT. Three months after the first CT, thrombi were no longer detected in 34 of 35 patients (97.1%). ConclusionsThrombosis can occur after surgical LAA occlusion. Although the clinical significance is yet unclear, it may be reasonable to continue anticoagulation therapy until a lack of thrombosis is confirmed, unless there are contraindications.

General dermatology and dermatology in primary healthcare.

Heparin-induced bullous haemorrhagic dermatosis is an uncommon cutaneous adverse reaction to heparin, thought to be under-reported owing to its relatively asymptomatic presentation and favourable prognosis. This vesiculobullous condition is largely self-limiting and tends to resolve spontaneously despite continued anticoagulant therapy. Correct identification can reassure clinicians and patients alike.

Factors associated with in-hospital and outpatient survival of patients with different types of stage IV cancer and venous thromboembolism.

To identify factors associated with in-hospital and outpatient survival of patients with different types of stage IV cancer who present with venous thromboembolic disease (VTE). In this prospective cohort, in-hospital and outpatient survival rates up to 180 days were analyzed using Kaplan-Meier curves. Cox regression was used to identify factors associated with different survival functions. One hundred patients were analyzed (median age, 67.5 years; 75% with Charlson index of <10; 69% with Eastern Cooperative Oncology Group (ECOG) score of 3-4). In-hospital mortality was 18%, and the median time from admission to death was 11 days (interquartile range, 1-61 days). Factors significantly associated with in-hospital mortality were the ECOG score and thrombocytopenia. The 180-day mortality rate was 52%, with deaths mainly occurring in the first 90 days since VTE diagnosis. Additional factors significantly associated with outpatient mortality included male sex and neoplasms with a high risk of thrombosis (lung, pancreas, stomach, uterus, bladder, and kidney neoplasms). Patients with stage IV cancer and acute VTE have short survival. Poor prognostic factors are thrombocytopenia, the ECOG score, and certain types of cancer. These results may help physicians individualize decisions regarding initiation and continuation of anticoagulant therapy.

Clinical characteristics and outcomes of super-low-dose edoxaban of 15 mg in patients with acute venous thromboembolism: insight from the COMMAND VTE Registry-2

Abstract Background/Introduction The current guidelines recommend specific durations of anticoagulation therapy depending on the risks of recurrent venous thromboembolism (VTE), and prolonged anticoagulation therapy is recommended for patients at not-low risk of recurrence. However, clinicians are sometimes reluctant to continue anticoagulation therapy for patients with high-bleeding risk. A recent study reported that super-low-dose edoxaban of 15 mg was useful in preventing thromboembolic events for elderly patients with atrial fibrillation who were considered as high-bleeding risk patients. However, super-low-dose edoxaban of 15 mg is currently off-label for VTE all over the world, which could be a potential option for patient with VTE at high-bleeding risk. Purpose The current study aimed to investigate clinical characteristics and outcomes of VTE patients with super-low-dose edoxaban of 15 mg, using a large-scale multicenter observational database of patients with VTE. Methods The COMMAND VTE Registry-2 is a multicenter registry enrolling 5197 consecutive acute symptomatic VTE patients among 31 centers in Japan between January 2015 and August 2020. After excluding 3193 patients without edoxaban as oral anticoagulation therapy, the current study population was consisted of 2004 patients with edoxaban, who were divided into 3 groups according to initial dosage of edoxaban; 60 mg/day (N=664, 33%) 30 mg/day (N=1309, 65%) and 15 mg/day (N=31, 1.5%). Results Patients with edoxaban of 15 mg/day were oldest (60 mg/day: 62.3 years, 30 mg/day: 72.9 years and 15 mg/day: 79.2 years, P&amp;lt;0.001), were most often women (44%, 73% and 84%, P&amp;lt;0.001), showed a lowest mean body weight (68.4, 51.9 and 48.7 kg, P&amp;lt;0.001). Pulmonary embolism as initial presentation was least frequent in patients with edoxaban of 15 mg/day (58%, 44% and 13%, P&amp;lt;0.001). Patients with edoxaban of 15 mg/day most frequently had chronic kidney disease (10%, 22% and 26%, P&amp;lt;0.001) and anemia (45%, 66% and 74%, P&amp;lt;0.001). The discontinuation rates of anticoagulation therapy were not significantly different among the 3 groups (54.4%, 56.5% and 64.8% at 3-year, Log rank P=0.38). The cumulative incidences of recurrent VTE were not significantly different among the 3 groups (6.0%, 6.6% and 0.0% at 3-year, Log rank P=0.31). Similarly, the cumulative incidences of major bleeding were not significantly different among the 3 groups (9.2%, 11.6% and 15.3% at 3-year, Log rank P=0.11). Conclusions In the current real-world large VTE registry, a very minority of VTE patients received edoxaban of 15 mg/day, including patients at high-bleeding risk such as old age, low body weight and chronic kidney disease, who did not show significant worse outcomes in terms of recurrent VTE.

Dynamic Patterns and Persistence of Anticoagulation Therapy in Patients with Venous Thromboembolism in South Korea: A Nationwide Cohort Study.

Venous thromboembolism (VTE) is associated with increased morbidity, mortality, and health care expenditure. However, the comprehensive utilization of anticoagulation therapy in patients with VTE, especially regarding active cancer, in real-world practice remains unclear. To describe the prescription, persistence, and patterns of anticoagulation therapy among patients with VTE stratified according to active cancer. Using Korean nationwide claims data, we identified an incident, treatment-naïve cohort of patients with VTE from 2013 to 2019 and classified them according to the presence/absence of active cancer. We explored the secular trends, treatment patterns (e.g., discontinuation, interruption, and switch), and persistence of anticoagulation therapy. There were 48,504 and 7,255 patients without and with active cancer, respectively. Non-vitamin K antagonist oral anticoagulants (NOACs) were the most common anticoagulant in both groups (65.1 and 57.9%, respectively). The prescription of NOACs increased steeply over time, regardless of active cancer, whereas parenteral anticoagulants (PACs) plateaued and warfarin decreased sharply. A heterogeneous pattern was observed between the groups without and with active cancer (3-month persistence was 60.8, 62.9, 57.2, and 3.4%, respectively; 6-month persistence was 42.3, 33.5, 25.9, and 1.2% vs. 9.9%). Median durations of continuous anticoagulant therapy for warfarin, NOAC, and PAC were 183, 147, and 3 days in nonactive cancer patients, and 121, 117, and 44 days in active cancer patients. Our findings suggest that there were substantial differences in persistence, patterns, and patient characteristics of anticoagulant therapy based on index anticoagulant and active cancer.

Trends in the Use of Oral Anticoagulants for Adults With Venous Thromboembolism in the US, 2010-2020

The introduction of direct oral anticoagulants (DOACs) has transformed the treatment of venous thromboembolism (VTE). Large health care databases offer valuable insight into how oral anticoagulants (OACs) are used in clinical practice and may aid in understanding reasons for changes in therapy. To evaluate prescribing patterns of OACs for patients with VTE and identify clinical events that precede treatment changes. This retrospective cohort study used data from a public (Medicare fee-for-service) and a commercial (IBM MarketScan) health insurance database on 298 609 patients initiating OACs within 90 days of index VTE hospitalization from January 1, 2009, to December 31, 2020. Statistical analysis was conducted from April to August 2022. Warfarin and the DOACs rivaroxaban, apixaban, dabigatran, and edoxaban. Characteristics of patients initiating different OACs, along with trends over time of patients initiating OACs, were compared. Time receiving continuous anticoagulant therapy, patterns of anticoagulant discontinuation (treatment gap of ≥30 days), and treatment switches were assessed. Clinical events in the 30 days preceding treatment modifications were identified. A total of 203 378 individuals with Medicare (mean [SD] age, 76.9 [7.6] years; 122 554 women [60.3%]) and 95 231 with commercial insurance (mean [SD] age, 57.6 [15.8] years; 47 139 women [49.5%]) were included (N = 298 609). Warfarin was the most frequent OAC prescribed (163 044 [54.6%]), followed by rivaroxaban (66 882 [22.3%]) and apixaban (65 997 [22.1%]). The proportion of patients initiating DOACs increased from 0% in 2010 to 86.8% (22 420 of 25 817) in 2019 for patients with Medicare and 92.1% (4012 of 4357) in 2020 for commercially insured patients. Patients with chronic kidney disease were more likely to initiate warfarin (35 561 [11.9%]) or apixaban (16 294 [5.5%]) than rivaroxaban (10 136 [3.4%]), and those with a history of bleeding were more likely to initiate apixaban (5424 [1.8%]) than rivaroxaban (3007 [1.0%]). Overall, patients received persistent OAC treatment for approximately 6 months (Medicare: median, 175 days [IQR, 76-327 days]; commercial insurance: median, 168 days [IQR, 83-279 days]). A total of 33 011 patients (11.1%) switched anticoagulant therapy within a year. Switching to another anticoagulant was preceded most frequently by codes for a VTE diagnostic procedure (27.2% of all switchers [8983 of 33 011]). This cohort study using data from 2 US health insurance databases suggests that most patients with VTE continued oral anticoagulant treatment for approximately 6 months. Clinical reasons for modifying anticoagulant therapy were identified in one-third of patients. Identifying reasons for treatment modification is crucial for generating valid evidence on drug safety and effectiveness.

Venous Thrombosis Due to Duplication of the Inferior Vena Cava with Decreased Protein C Activity: A Case Report

Introduction: Duplication of the inferior vena cava (IVC) is a congenital venous malformation that occurs in 0.2%-3% of the population as a result of persistent left and right supracardinal veins. The IVC duplication is prone to deep vein thrombosis due to endothelial dysfunction and associated venous stasis. This is a rare case of recurrent venous thrombosis due to IVC duplication and decreased protein C activity. Case: A 57-year-old male presented with swelling of the left lower limb that gradually developed over a one-week period preceding his visit. He reported a history of superior mesenteric vein thrombosis, approximately three years ago, for which he received anticoagulation therapy for three months. Thoracoabdominal contrast-enhanced computed tomography (CT) revealed thrombi in the locations of the bilateral main pulmonary arteries, IVC duplication, left common iliac vein, left IVC, and left renal vein. Blood work confirmed protein C activity of 21% (baseline 64%-146%), that could have contributed to the recurrent IVC thrombosis and formation of pulmonary artery thrombus. Subsequently, the patient was hospitalized and started on anticoagulation therapy. The swelling in the left lower extremity gradually improved, and the patient was instructed to continue anticoagulation therapy permanently. Conclusion: When investigating venous thrombosis of unknown or recurrent origin, it is necessary to include venous malformations and abnormal activity of blood coagulation factors in differential diagnosis.

New prospects for assessing the hemostasis system in atrial fibrillation and left atrial appendage thrombosis

Thromboembolic syndrome, the frequency of which is 8–15%, is the main danger for a patient with atrial fibrillation (AF). The left atrial appendage is the most common source of thromboembolia in atrial fibrillation. The frequency of detection of left atrial appendage thrombus in AF is 15.2% in the absence of anticoagulant therapy and 1–8% in patients using this group of drugs. The reason for the formation of thrombi in this localization during anticoagulant therapy today it is not reliably known. This article describes a clinical case of a 67-year-old patient with persistent AF and left atrial appendage thrombosis, who was hospitalized to determine further management strategies. A left atrial appendage thrombus lasted for a year despite continuous anticoagulant therapy with various oral anticoagulants at doses consistent with clinical guidelines due to the patient's absolute refusal to take warfarin, vitamin K antagonist. In addition, this article discusses the use of Thrombodynamics, a new global coagulation test, in patients with AF, which revealed a plasma hypercoagulable state with underlying persistent thrombosis in this patient on continuous oral anticoagulant treatment. The Thrombodynamics test is a promising procedure for assessing the coagulation system state and may be promising as a method for measuring the effectiveness of any oral anticoagulant. However, it is impossible to draw any definite conclusions on the basis of single observations; large clinical studies with the potential of long-term case follow-up of patients are needed.

Importance of gradual induction in oral anticoagulation therapy in a patient with heparin-induced thrombocytopenia with a left ventricular assist device: a case report

BackgroundWe encountered a case of a patient with heparin-induced thrombocytopenia (HIT) who developed multiple thromboses following implantable left ventricular assist device (iLVAD) implantation. We herein report this case along with a literature-based discussion on the timing of warfarin initiation for such patients.Case presentationA 15-year-old boy was rushed to our hospital due to cardiogenic shock associated with multiple organ dysfunction. A detailed examination, including cardiac catheterization and right heart biopsy, provided a diagnosis of dilated cardiomyopathy, for which an iLVAD placement as a bridge to cardiac transplantation was scheduled after the transplant workup. Three days before the surgery, the patient’s platelet count decreased drastically from 110,000 to 40,000/µL, suggesting HIT, and his blood sample was sent to a specialized laboratory outside our hospital. The HIT antibody test came back positive during the iLVAD implantation using heparin. Thus, we chose argatroban over heparin for postoperative anticoagulation therapy, which was initiated 6 h after the surgery. The day after surgery, the patient was successfully weaned off mechanical ventilation and extubated. Oral anticoagulation therapy with warfarin was also initiated; however, on postoperative day 2, contrast-enhanced computed tomography revealed multiple thrombi in the left iliac artery, right iliac vein, and right jugular vein. We suspected hypercoagulation associated with the initiation of warfarin, prompting us to suspend warfarin and continue anticoagulation therapy with argatroban alone. On postoperative day 8, the patient’s platelet count increased to 130,000/µL despite not reaching the normal range and showed two consecutive increases; therefore, we resumed oral warfarin, concerning the efficacy of argatroban as an anticoagulant for iLVAD. Thromboembolism did not recur; the patient was discharged 50 days after the operation and is currently awaiting heart transplantation.ConclusionsWe encountered a case of HIT type II in which multiple thromboses occurred following iLVAD implantation. If HIT antibodies are detected, it is crucial to initiate argatroban monotherapy and wait to start oral anticoagulation therapy with warfarin until platelet count has improved.

Analysis of 8 cases of asparaginase related cerebral venous sinus thrombosis in children

Objective: To summarize the clinical features, treatment and prognosis of asparaginase (ASP) related cerebral venous sinus thrombosis (CVST). Methods: Clinical profiles including age, sex, first symptoms, coagulation function, imaging findings, ASP type, treatment and prognosis of eight acute lymphoblastic leukemia (ALL) or lymphoblastic lymphoma (LBL) children with ASP related CVST at the Department of Pediatrics, First Affiliated Hospital of Zhengzhou University from November 2016 to October 2021 were analyzed retrospectively. Results: Eight CVST children were all male, including 6 ALL and 2 LBL, with the onset age ranged from 5 to 15 years, 6 cases occurred in the stage of first induction remission, and the initial symptom were mainly epileptic seizures (7 cases). Magnetic resonance imaging combined magnetic resonance venography (MRV) showed the most common site of venous sinus enlargement was superior sagittal sinus (8 cases). Secondary cerebral hemorrhage was found in 5 cases. D-dimer elevated on the day of onset in all cases. Three patients were treated with intravascular mechanical thrombectomy and thrombolysis combined with anticoagulant therapy, 3 patients were treated with continuous anticoagulant therapy only, 2 patients were not treated with anticoagulant therapy. MRV follow-up for 3 months showed that the thrombi in patients were almost completely absorbed except in 2 patients who were not treated with anticoagulant therapy. Thrombolysis combined with anticoagulant therapy was the fastest way for thrombosis absorption. Among 8 patients, 1 died of early recurrence of ALL, and 7 patients accepted further asparaginase and no CVST recurrence or progression was found. There were no sequelae of nervous system except 1 patient with left upper limb muscle strength impairment. Conclusions: ASP related CVST is more common in older male children and the prognosis is good. ASP related CVST occurred mostly in the stage of first induction remission, and most initial manifestation is epileptic seizure. The superior sagittal region is a common site of thrombus, magnetic resonance imaging combined with MRV is helpful for accurately diagnosis. Timely anticoagulant treatment can improve the prognosis, and mechanical thrombectomy and thrombolysis can quickly recanalize the vessel.

Anticoagulation Changes Following Major and Clinically Relevant Nonmajor Bleeding Events in Non-valvular Atrial Fibrillation Patients

Background: Bleeding events are common complications of oral anticoagulant drugs, including both warfarin and the direct oral anticoagulants (DOACs). Some patients have their anticoagulant changed or discontinued after experiencing a bleeding event, while others continue the same treatment. Differences in anticoagulation management between warfarin- and DOAC-treated patients following a bleeding event are unknown. Methods: Patients with non-valvular atrial fibrillation from six anticoagulation clinics taking warfarin or DOAC therapy who experienced an International Society of Thrombosis and Haemostasis (ISTH)-defined major or clinically relevant non-major (CRNM) bleeding event were identified between 2016 and 2020. The primary outcome was management of the anticoagulant following bleeding (discontinuation, change in drug class, and restarting of same drug class). DOAC- and warfarin-treated patients were propensity matched based on the individual elements of the CHA2DS2-VASc and HAS-BLED scores as well as the severity of the bleeding event. Results: Of the 509 patients on warfarin therapy and 246 on DOAC therapy who experienced a major or CRNM bleeding event, the majority of patients continued anticoagulation therapy. The majority of warfarin (231, 62.6%) and DOAC patients (201, 81.7%) restarted their previous anticoagulation. Conclusion: Following a bleeding event, most patients restarted anticoagulation therapy, most often with the same type of anticoagulant that they previously had been taking.

Interrupted versus uninterrupted anticoagulation therapy for catheter ablation in adults with arrhythmias.

Interrupted versus uninterrupted anticoagulation therapy for catheter ablation in adults with arrhythmias.

Practical aspects of antithrombotic therapy in patients with atrial fibrillation and coronary artery disease

Atrial fibrillation (AF) is the most common cardiac arrhythmia, which is associated with an increased risk of cardiovascular death. The latter is partly due to the common combination with coronary artery disease (CAD). If indicated, patients with AF need continuous direct oral anticoagulant therapy to prevent thromboembolic events. In addition, patients with CAD who require urgent or elective percutaneous coronary intervention require dual antiplatelet therapy. Therefore, physicians often face a dilemma when choosing the most appropriate antithrombotic therapy regimen for AF patients undergoing percutaneous coronary intervention. Integrating two medication approaches to treat a single patient with a combination of AF and CAD is challenging and must strike a balance between high efficacy and safety. This article provides an overview of studies on this issue.

A prospective comparative study to assess the risk of postoperative bleeding after dental surgery while on medication with direct oral anticoagulants, antiplatelet agents, or vitamin K antagonists

BackgroundThe aim of this prospective study was to investigate the occurrence and severity of postoperative bleeding following dentoalveolar surgery in patients with uninterrupted anticoagulation therapy (AT).MethodsPatients receiving AT (vitamin k antagonist (VK), direct oral anticoagulants (DOAC) or antiplatelet therapy (APT) and in need of surgical intervention classified as A, B or C (single or serial tooth extraction, osteotomy, or implant placement) were studied between 2019 and 2021. A healthy, non-anticoagulated cohort (CG) served as a control group. The main outcomes measured were the frequency of postoperative bleeding, the classification of the severity of postoperative bleeding (1a, 1b, 1c, 2, 3), and the correlation with the AT surgical intervention classification.ResultsIn total, 195 patients were included in the study, with 95 patients in the AT group and 100 in the CG. Postoperative bleeding was significant in the AT group vs. the CG (p = 0.000), with a significant correlation with surgical intervention class C (p = 0.013) and the severity class of bleeding 1a (p = 0.044). There was no significant correlation with procedures of type A, B or C for the other postoperative bleeding gradations (1b, 1c, 2 and 3). There was a statistically significant difference in the occurrence of postoperative bleeding events between the DOAC/APT group and the VK group (p = 0.036), but there were no significant differences regarding the other AT agents.ConclusionThe continuation of anticoagulation therapy for surgical interventions also seems reasonable for high-risk interventions. Although significantly more postoperative bleeding occurs, the severity of bleeding is low. The perioperative management of anticoagulated patients requires well-coordinated interdisciplinary teamwork and detailed instruction of patients.Clinical trial registration The study is registered (29.03.2021) at the German clinical trial registry (DRKS00024889).

A Novel Use of Suction Thrombectomy for Embolic Protection During Mechanical Ileocaval Thrombectomy

We have reported on a novel use of the AngioVac suction thrombectomy device (AngioDynamics, Latham, NY) for vacuum-assisted embolic protection in a case of extensive mechanical thrombectomy of a caval–visceral deep vein thrombosis (DVT) that was refractory to standard catheter-directed thrombolysis. To the best of our knowledge, this is the first report of the use of a vacuum-assisted suction thrombectomy device for successful embolic protection. A 15-year-old girl had developed extensive, symptomatic bilateral ileocaval and renal vein DVTs refractory to outpatient management with anticoagulation therapy after pharmacomechanical thrombectomy and catheter-directed lysis. Initially, she had been treated successfully with overnight lytic therapy for the ileocaval DVT, and she was discharged with anticoagulation therapy. However, she had presented again with worsening bilateral lower extremity symptoms and kidney injury due to progression of the DVT. To prevent end-organ failure, extensive endovascular mechanical thrombectomy was planned. With the patient's significant thrombus burden through the visceral and retrohepatic inferior vena cava (IVC), pulmonary embolic protection during mechanical thrombectomy was our chief concern. Given the extent of the clot, IVC filter placement was impossible. Therefore, an AngioVac suction thrombectomy cannula and circuit was established via bilateral internal jugular vein access in an attempt to debulk the thrombus from a superior approach and provide pulmonary embolic protection. Mechanical thrombectomy (ClotTriever; Inari Medical, Irvine, Calif) was used to successfully debulk the IVC and bilateral ileofemoral venous segments from the bilateral popliteal veins. Although the use of the AngioVac from above proved unable to debulk the thrombus, it was successful in preventing significant embolism during ClotTriever mechanical thrombectomy (Fig 1). After mechanical thrombectomy (Fig 2), the patient's creatinine had returned to normal. She continued anticoagulation therapy, with Doppler ultrasound imaging showing reduction of the DVT and improvement of her lower extremity symptoms. We believe the present case has illustrated successful pulmonary embolic protection using a large-bore suction thrombectomy device with venoveno bypass during endovascular mechanical thrombectomy of caval, visceral, and bilateral ileofemoral DVTs. The AngioVac cannula and circuit can be safely and effectively used for central embolic protection in the case of large-volume caval mechanical thrombectomy.Fig 2Doppler ultrasound image showing reduction of the deep vein thrombosis (DVT) after mechanical thrombectomy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Risk of bleeding following double balloon enteroscopy in patients on continued antiplatelet and/or anticoagulation therapy.

Background and study aims Anticoagulation (AC) and antiplatelet (AP) therapy may increase the risk of gastrointestinal bleeding after double balloon enteroscopy (DBE); however, limited data are currently available regarding the incidence. The aim of this study was to assess the incidence and clinical characteristics of post-DBE bleeding in patients on AC and AP therapy. Patients and methods The medical records of patients who underwent DBE between 2009 and 2013 at Mayo Clinic, Florida, were retrospectively reviewed. Patients were divided into three groups: 1) continued AP therapy; 2) AC therapy; and 3) neither AP nor AC at the time of DBE. Follow-up data were collected at 60 days and 1 year. Results A total of 683 patients were identified; 43 on AC, 183 on AP and 457 not on AP or AC therapy. The most common indication for DBE was obscure gastrointestinal bleeding in the groups on and not on AP (85.3 % vs 70.9 %, P < 0.0001). There was no statistical difference in post-DBE bleeding rates in patients on AP vs not on AP at 60 days (11.5 % vs 7.5 %, P = 0.12) or 1 year (19.9 % vs 15.7 %, P = 0.23). Rates of bleeding in patients on AC were 11.6 % within 60 days and 22.5 % within 1 year. Multivariate analysis reflected American Society of Anesthesiologist > 3 and indication for DBE of GI bleeding were independent risk factors for post-DBE bleeding within 1 year. Conclusions Continued antiplatelet use at the time of DBE was not an independent risk factor for bleeding post-DBE at 60 days or 1 year of follow up.

Atrial standstill in the newborn: a case report

Introduction. Persistent atrial standstill is a rare syndrome characterized by absence of mechanical and electrical atrial activity. The article presents a unique case of atrial standstill in the newborn patient with tachyarrhythmia.Brief description. The first manifestation of atrial standstill in the patient was heart failure (HF) manifestations and wide-complex tachycardia according to electrocardiography, which was identified as ventricular tachycardia. At the local outpatient clinic, the child was prescribed with antiarrhythmic therapy (AAT), which decreased heart rate. Three months later, a transesophageal electrophysiological study was carried out in our center in order to determine the arrhythmia origin. A multiform idioventricular rhythm with a heart rate of 46-119 beats per min was diagnosed, atrial pacing spike (A waves) was not recorded. Given bradyarrhythmia, hemodynamic abnormalities on echocardiography (significant atrial enlargement, decreased contractility), the patient, in order to prevent the risk of sudden cardiac death, underwent implantation of single chamber pacemaker in VVIR mode and bipolar ventricular lead. Anticoagulant therapy was prescribed. After 6-month follow-up, relief of HF symptoms and an increase in left ventricular contractile function was noted.Discussion. Timely diagnosis and implantation of pacemakers allowed avoiding AAT and minimizing the HF symptoms. Continuous ventricular pacing and anticoagulant therapy are important in HF prevention.

Spontaneous giant rectus sheath hematoma in patients with COVID-19: two case reports and literature review

IntroductionCoronavirus disease 2019, COVID-19, as a global public health emergency, has come with a broad spectrum of clinical manifestations and complications. In this study, we present a unique complication of this disease.Presentation of cases(A) A 65-year-old woman with a known case of COVID-19; on the second day of admission, the patient presented sudden tachycardia and hypogastric pain; on abdomen physical examination, a huge lower abdominal tender mass was noticed. (B) A 50-year-old woman with COVID-19, 4 days after admission, started complaining of tachycardia, pain, and mass in the lower abdomen. On abdomen physical examination, a huge lower abdominal tender mass was noticed. Both of the patients underwent an abdomen CT scan which confirmed a huge rectus sheath hematoma (RSH). Both of the patients underwent angioembolization of the inferior epigastric artery. The patient recovered completely and no evidence of further expansion was seen after 2 weeks of follow-up.DiscussionHemorrhagic issues in COVID-19 patients remain poorly understood. Physicians should discuss risks of RSH in patients where continuous anticoagulation therapy will be reinstated. With increased clinician awareness of the need for RSH screening in COVID-19 patients with acute abdominal pain, the interprofessional team of healthcare providers can maximize patient safety and reduce hospitalization time, especially in high-risk patients at risk for unnecessary surgery.ConclusionsThese two reports and literature review demonstrate the need of active surveillance for possible hemorrhagic complications in patients with COVID-19 infection.