Duration Of 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.

Comparing clinical outcomes of vitamin K antagonists vs non-vitamin K antagonists in anticoagulant therapy for mesenteric venous thrombosis

ObjectiveNon-vitamin K antagonist oral anticoagulants have shown similar efficacy and lower bleeding rates than vitamin K antagonists for venous thromboembolism. However, this has not been proven in mesenteric vein thrombosis. This study aimed to compare the clinical outcomes of vitamin K antagonists and non-vitamin K antagonist oral anticoagulants. MethodsBetween January 2014 and July 2022, mesenteric vein thrombosis was diagnosed on computed tomography in 225 patients in a tertiary hospital. Among them, a total of 44 patients who underwent long-term anticoagulation therapy over 3 months were enrolled in this study. Patients were divided into two groups based on the anticoagulant used: vitamin K antagonists (Group 1, n = 21) and non-vitamin K antagonist oral anticoagulants (Group 2, n = 23). The efficacy outcomes were symptom recurrence and thrombus resolution on follow-up computed tomography, and the safety outcome was bleeding complications. ResultsThe median age of the patients was 56 years (range, 46-68 years), and 52% were men. The most common risk factors were unprovoked intra-abdominal infections (30%). The median duration of anticoagulation therapy was 13 months (20 months in Group 1 vs 6 months in Group 2; P = .076). Of the 44 patients, 17 (39%) received the standard treatment. The median follow-up period was longer in Group 1 than in Group 2 (57 vs 28 months; P = .048). No recurrence of mesenteric vein thrombosis-related symptoms were observed in either group. The median duration of follow-up computed tomography was 31 months (42 months in Group 1 vs 18 months in Group 2; P = .064). Computed tomography revealed complete thrombus resolution, partial resolution, and no changes in 71%, 19%, and 10%, respectively (P = .075). Regarding bleeding complications, varix bleeding and melena developed in two patients in Group 2, and anticoagulation treatment thereafter ceased. ConclusionsDespite the short follow-up duration in the non-vitamin K antagonist oral anticoagulants group, there was no clinically significant difference in the thrombus resolution rate or bleeding complications when compared with the vitamin K antagonists group. Although research on the long-term effects of non-vitamin K antagonist oral anticoagulants in patients is limited, non-vitamin K antagonist oral anticoagulants can be considered an alternative to conventional treatments.

Biomarkers Profile in Provoked Versus Unprovoked Deep Venous Thrombosis.

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), represents a substantial healthcare challenge. Provoked and unprovoked DVT cases carry distinct risks and treatment considerations. Recognizing the limitations of this classification, molecular markers may enhance diagnostic precision and guide anticoagulation therapy duration relying on patient history and risk factors. This preliminary, open-label, prospective cohort study was conducted including 15 patients (10 provoked DVT and 5 unprovoked DVT) and a control group of healthy plasmatic subjects. Plasma levels of 9 biomarkers were measured at diagnosis (baseline, day 0, and D0) and after 30 days (day 30-D30). Patient demographics, clinical data, and biomarker concentrations were analyzed. Serum concentrations of D-dimer, von Willebrand factor, C-reactive protein, and Anti-Xa were elevated in DVT groups at D0 compared to controls. No significant differences were observed between the provoked and unprovoked groups on the day of diagnosis and 30 days later. Over 30 days, the provoked group exhibited significant biomarker changes related to temporal assessment. No significant differences were noted in the biomarker profile between provoked and unprovoked DVT groups. This study is indicative of the concept of individualized thrombosis assessment and subsequent treatment for VTE. Larger cohorts are warranted to validate these findings and further define the most appropriate use of the molecular markers.

Accuracy of the Diagnosis of Subsegmental Pulmonary Embolism Among General Radiologists

Background: Diagnosis and treatment of subsegmental pulmonary embolism (SSPE) are challenging. Contrary to segmental PE, little is known about the accuracy of the diagnosis of SSPE Methods A retrospective matched cohort study was conducted at a university-affiliated community hospital. Computed tomographic angiography (CTAs) were reviewed from August 2018 to December 2021. Patients who were 18-year-old or older with the diagnosis of SSPE were included. Patients with a concurrent segmental PE or deep venous thrombosis (DVT) were excluded. Another radiologist reviewed each CTA. Results Total of 43 patients with SSPE without segmental PE were identified. The mean age of subjects was 67 years. 24 (56%) patients were males, and 41 (95%) were white. 42 (97%) of CTAs were performed for suspected PE. One case was found incidentally. Forty patients (93%) received therapeutic anticoagulation. Three patients (7%) were discharged from the Emergency Department (ED) without therapeutic anticoagulation. The average duration of anticoagulation therapy was four-months. Another radiologist's review of the CTA on admission revealed a discordant diagnosis: 13 out of 43 (30%) cases were reported negative for SSPE. One case was reported for segmental PE Conclusion The accuracy of the diagnosis of SSPE is low as the discordance rate by different radiologists is high.More studies are needed to establish the diagnosis and guide treatment of SSPE.

Short versus long-term anticoagulation for left ventricular thrombosis resolution during vitamin k antagonist therapy

Abstract Background The optimal duration of anticoagulant therapy to achieve thrombus resolution and prevent cardioembolic events in left ventricular thrombosis (LVT) has not yet been established. Purpose The purpose of our study is to evaluate the incidence of LVT resolution at 3 versus 12 months of vitamin K antagonists (VKAs) therapy. Methods Consecutive patients diagnosed with LVT and treated with VKAs for at least 12 months at 5 anticoagulant outpatient clinics in Italy were retrospectively included. The primary effectiveness outcome was on-treatment thrombus resolution while the secondary was objectively documented on-treatment acute ischemic stroke, peripheral embolism, and myocardial infarction at 12-months follow-up. Safety outcomes were on-treatment major and clinically relevant non-major bleedings at 12-months follow-up as defined by the ISTH criteria. Cumulative incidences of thrombus resolution with 95% confidence intervals (CIs) were calculated while other outcomes were descriptively reported. Multivariable Cox hazards models were calculated using age, sex, reduced left ventricular ejection fraction (EF < 35%), VKAs monotherapy, and time in therapeutic range (TTR) below 60% as covariates for thrombus persistence at 12-months of follow-up. Results Out of 95 patients, 87 were finally included (Table) and 8 excluded due to the lack of relevant data. Median age was 67 years and 75.9% were men. A total of 64.4% of patients had acute myocardial infarction as risk factor for LVT development while 21.8% and 5.7% of patients had dilated and primary hypertrophic cardiomyopathy, respectively. A reduced EF and atrial fibrillation were present in 77.0% and 19.5% of patients, respectively. All but one patient received warfarin with a median TTR of 54%, and 35.5% of patients did not receive concomitant antiplatelet therapy. All included patients received VKAs for at least 12-months. The 3 and 12 month cumulative incidences (Figure) of thrombus resolution were 34.5% (95% CI, 24.7%-44.5%) and 68.3% (95% CI, 57.2%-77.1%), respectively. At multivariable Cox regression analysis, the presence of a reduced EF appeared to be associated with a higher risk of thrombus persistence at 12-months follow-up (Hazard Ratio 3.09; 95% CI 1.27-7.55; p=0.013). During 12-months follow-up, two patients (2.3%) had acute ischemic stroke at 4 and 7 months from the start of VKAs therapy. Three patients (3.4%) had a major and 5 (5.7%) a clinically relevant non-major bleeding that occurred within the first three months of VKAs. Conclusions A 12-month course of anticoagulant therapy with VKA appeared to be effective and safe in patients with LVT and appeared to be associated with a higher cumulative incidence of LVT resolution than a 3-month course. A reduced left ventricular EF was associated with a higher risk of LVT persistence. Whether anticoagulant agents with improved ease-of-use and safety profile are effective in this setting remains undefined.Baseline patients' characteristicsCumulative incidences of LVT resolution

Clinical long-term outcomes in fragile patients with venous thromboembolism receiving direct oral anticoagulant: From the COMMAND VTE Registry-2

Abstract Background In patient with venous thromboembolism (VTE), assessment of risk of the opposing complications, major bleeding and recurrent VTE, is clinically imperative to determine the duration of anticoagulation therapy. Patients with VTE and fragility (age ≥75 years, creatinine clearance level ≤50 ml/min, and/or body weight ≤50 kg) are reportedly at increased risk of bleeding complications associated with anticoagulant. However, there is lack of real-world data with respect to bleeding risk in fragile patients with VTE receiving direct oral anticoagulant (DOAC). Purpose The current study aimed to assess the relationship between fragility and long-term outcomes in such patients. Methods The COMMAND VTE Registry-2 is a multicenter registry enrolling 5,197 consecutive acute symptomatic VTE patients among 31 centers in Japan between January 2015 and August 2020. The current study population consisted of 3,928 patients with treatment with DOAC and available data of body weight and serum creatine level, who were divided into a fragile group (N=2,136, 45.6%) and a non-fragile group (N=1,792, 54.4%). The primary outcomes were major bleeding and recurrent VTE. Results In the entire study population, the mean age was 68±15 years, 59% was women, and mean body weight, body mass index, creatinine clearance level were 59.2±14.1 kg, 23.4±4.4 kg/m², and 67.8 (49.1-94.2) ml/min, respectively. The fragile group showed a higher proportion of female and higher prevalence of several comorbidities including hypertension and history of stroke than the non-fragile group, while there was not statistically difference in diabetes mellitus, liver cirrhosis, autoimmune disorder, active cancer, history of VTE, history of major bleeding, and transient VTE risk factor between the two groups. As for laboratory test, the fragile group showed higher prevalence of anemia. The fragile group more often received off-label doses of DOAC, while discontinuation of anticoagulation therapy was not statistically different between the two groups. There was a significantly difference in the cumulative 5-year incidence of major bleeding between the two groups but not in the cumulative 5-year incidence of recurrent VTE (the fragile group, 15.0% vs the non-fragile group, 11.1%, P = 0.049; and 9.6% vs 8.9%, P = 0.38, respectively). However, after adjusting for potential confounders, the excess risk of the fragile group relative to the non-fragile group was not statistically significant for major bleeding or recurrent VTE (adjusted HR 1.09, 95%CI 0.87-1.37, P = 0.47 and adjusted HR 1.06, 95%CI 0.80-1.41, P = 0.67, respectively). Conclusions In the multivariate analysis with data from the current large-scale observational study, there was not statistically significant association between the fragility and major bleeding or recurrent VTE in patient receiving DOAC.

What should a general practitioner know about the management of patients with venous thromboembolism?

The era of the Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV-2) virus has shown that non-core specialists can be involved in the treatment of epidemic diseases. However, the entire burden for the prevention and treatment of venous thromboembolism (VTE) falls on doctors – cardiovascular surgeons, phlebologists. It should be borne in mind that most of the thromboses – more than 2 million cases per year – are asymptomatic, and only a small part has pulmonary embolism, pulmonary hypertension, and death. The survival rate of patients with deep vein thrombosis (DVT) for 8 years is 65 %, with a combination of DVT with pulmonary embolism; the survival rate does not exceed 34 %, so a doctor of any specialty should know how to suspect VTE. The clinical picture of DVT is not always pronounced. Most often, with DVT, patients complain of swelling and pain in the affected lower limb, a decrease in the volume of active movements, and skin cyanosis. Diagnosis of DVT and thromboembolic complications at the non-specialized level should initially consist of assessing the risk of VTE using special scales, among which the Wales scale is of the greatest importance. The gold standard for diagnosing DVT is duplex ultrasound. Among the main indicators for hospitalization is not the fact of the established diagnosis of DVT, but the presence of comorbid pathology, chronic lung diseases, and old age. Additional risk factors include extended DVT, suspected pulmonary embolism, and pregnancy. The goal of anticoagulant therapy is to stop the process of pathological hypercoagulability, the progression of thrombus formation and create conditions for restoring vascular patency, while the pathological idea is that anticoagulants “dissolve the thrombus”. In this regard, anticoagulant therapy is the mainstay of treatment for DVT. To determine the duration of anticoagulant therapy, the etiology of thrombosis is of particular importance – the trigger that led to the formation of thrombotic masses.

Intensify Standardized Anticoagulation for Cancer-associated Pulmonary Embolism: From Single-center Real-world Data

Pulmonary embolism (PE) is a significant contributor to mortality in patients with cancer. Although anticoagulation serves as the cornerstone of treatment for cancer-associated PE, it has not been emphasized in real-world settings. The aim of this study was to examine the impact of suboptimal anticoagulant treatment on the prognosis of cancer-associated PE. A cohort of 356 individuals newly diagnosed with acute PE were enrolled. The primary outcome of the study was recurrent venous thromboembolism (VTE), and the secondary outcomes were all-cause mortality and major bleeding (consisting of a reduction in the hemoglobin level by at least 20 g/L, transfusion of at least 2 units of blood, or symptomatic bleeding in a critical area or organ or fatal bleeding). Of the total participants, 156 (43.8%) were diagnosed with cancer. A comparison between the cancer and noncancer groups revealed that patients with cancer were more frequently asymptomatic (41.0% vs 4.5%; P < 0.001), less likely to have right ventricular dysfunction (4.5% vs 14.0%; P=0.001), received less anticoagulant treatment during hospitalization (85.3% vs 98.5%; P < 0.001), and had a shorter duration of anticoagulation (5.02 [7.40] months vs 14.19 [10.65] months; P < 0.001). In addition, patients with cancer were found to be at a higher risk of recurrent VTE (17.3% vs 4.0%; P < 0.001) and all-cause mortality (23.7% vs 10.5%; P=0.001). Multiple Cox regression analysis indicated that discontinuation of anticoagulation at 3 months was a significant risk factor for recurrent VTE in the cancer group (HR, 15.815; 95% CI, 3.047-82.079; P=0.001). The brief duration of anticoagulation therapy and elevated likelihood of recurrent VTE serve as cautionary indicators for the need to enhance awareness of standardized anticoagulant treatment for cancer-associated PE. The ultimate goal is to enhance patient prognosis and quality of life.

Incidence of recurrent venous thromboembolism and bleeding complications in patients with cancer and isolated distal deep vein thrombosis

BackgroundIsolated distal deep vein thrombosis (IDDVT) is a common clinical presentation of DVT. The efficacy and safety of anticoagulant therapy for the management of IDDVT in patients with cancer are unclear. We sought to assess the incidence of recurrent venous thromboembolism (VTE) and major bleeding in this patient population. MethodsA systematic search of MEDLINE, EMBASE and PubMed, from inception to June 2, 2022 was performed. The primary efficacy outcome was recurrent VTE and the primary safety outcome was major bleeding. The secondary outcomes were clinically relevant non-major bleeding (CRNMB) and mortality. The incidence rates of thrombotic, bleeding, and mortality outcomes were pooled using random effects model and expressed as events per 100 patient-months with associated 95 % confidence intervals (CI). ResultsOut of a total of 5234 articles, 10 observational studies including 8160 patients with cancer and IDDVT were included in the analysis. The incidence rate of recurrent VTE was 5.65 (95 % CI: 2.09–15.30) per 100 patient-years regardless of type and duration of anticoagulant therapy. The incidence rate of major bleeding was 4.08 (95 % CI: 2.52–6.61) per 100 patient-years. The incidence rates for CRNMB and mortality per 100 patient-years were 8.11 (95 % CI: 5.56–11.83) and 30.22 (95 % CI: 22.60–40.42.89), respectively. ConclusionPatients with cancer and IDDVT are at high risk of developing recurrent VTE and bleeding complications (both major bleeding and CRNMB). More studies are needed to define the optimal management for this high-risk population.

Residual Venous Obstruction as an Indicator of Clinical Outcomes following Deep Vein Thrombosis: A Management Study.

Residual venous obstruction (RVO) is considered a risk factor of recurrence and possibly other clinical outcomes following deep vein thrombosis (DVT). Current guidelines do not support an RVO-tailored duration of anticoagulant therapy; contemporary data of such management strategies are scarce. We aimed to evaluate an RVO-based management strategy and to assess associations of RVO with recurrence, post-thrombotic syndrome (PTS), arterial events and cancer. To gain further insight, D-dimer levels were measured 1 month after stopping anticoagulant therapy. Consecutive patients with symptomatic, proximal DVT were treated in a 2-year clinical care pathway (CCP) at Maastricht University Medical Center and were followed up to 5 years. RVO was assessed at the end of regular duration of anticoagulant therapy, which was extended once if RVO was detected. The study was approved by the medical ethics committee. From a total of 825 patients, 804 patients (97.5%) completed the CCP and 755 (93.9%) were available for extended follow-up. Most patients (76.5%) stopped anticoagulant therapy. Incidence rates of recurrence, PTS, arterial events, and cancer were 4.4, 11.9, 1.7, and 1.8 per 100 patient-years, respectively. RVO was independently associated with PTS (hazard ratio [HR]: 1.66 [1.19-2.32]) and arterial events (HR: 2.07 [1.18-3.65]), but not with recurrence or cancer. High D-dimer was associated with recurrence (HR: 3.51 [2.24-5.48]). Our RVO-based management strategy might have attenuated the association of RVO with recurrence. In addition, RVO identified patients at increased risk of PTS and arterial events, which might be used to identify patients in need of alternative treatment strategies.

Quality of anticoagulation with the use of warfarin in long-term care in a tertiary care hospital using time spent in therapeutic range as a predictive parameter

ABSTRACT Background: Warfarin was a frequently prescribed long-term anticoagulant before the advent of novel oral anticoagulants or direct oral anticoagulants. These drugs are used for the primary or secondary prevention of stroke in patients with atrial fibrillation or for the treatment and prophylactic prevention of venous thromboembolism. This study aimed to assess the anticoagulation control of patients receiving warfarin at a tertiary care hospital. Methods: This retrospective cohort study was conducted in an anticoagulation clinic at a tertiary care hospital in Saudi Arabia and included 113 patients who had been treated with warfarin for at least 3 months. Thereafter, the international normalized ratio results were collected for 3 years. Anticoagulation control was assessed by calculating time within the therapeutic range (TTR) as per the Rosendaal method. Results: A total of 113 patients (mean age, 56 ± 17.6 years; 64.6% of females) were included. The mean TTR was 48.1%. Almost one-third of the patients (31.3%) had poor anticoagulation control defined as a TTR of &lt;50%. Poor anticoagulation control was significantly associated with a higher CHADS2 (congestive heart failure, hypertension, age, diabetes, and stroke/transient ischemic attack) score (P = 0.043). TTR did not differ significantly between men and women, and it was not associated with age or anticoagulation therapy duration. Conclusion: Anticoagulation quality was suboptimal in patients receiving warfarin in a tertiary care hospital, with nearly 41% of time spent outside the therapeutic range. Methods should be implemented to improve anticoagulation control in appropriate patient groups.

Protocol for a modelling study to assess the clinical and cost-effectiveness of indefinite anticoagulant therapy for first unprovoked venous thromboembolism

IntroductionDeciding whether to stop or extend anticoagulant therapy indefinitely after completing at least 3 months of initial treatment for a first unprovoked venous thromboembolism (VTE) remains a challenge for clinicians,...

Knowledge and practicing pattern of patients following oral anticoagulant therapy in a tertiary health-care center

Background: Oral anticoagulant therapy is frequently used for the diagnosis, treatment, and prevention of heart diseases. Oral anticoagulants need to be constantly managed when used long term and outside of a hospital setting since they have a restricted therapeutic index. Oral anticoagulants have been associated with a number of issues, including bleeding. Patients’ health can be enhanced by educating patients about their oral anticoagulant therapy which can enhance long-term adherence to the therapy. Aims and Objectives: The objective was to evaluate how well oral anticoagulant therapy users comprehended the drug, in addition to providing the patients with the appropriate education. Materials and Methods: This cross-sectional study was conducted on 200 patients on oral anticoagulant therapy in a tertiary care hospital. A standardized questionnaire was circulated to 200 patients and institutional ethical approval was taken before the study. Data were evaluated using Statistical Package for the Social Sciences software. Descriptive analysis and Chi-square tests were used for data analysis. For significance P ≤ 0.05 was considered. Results: The majority (36.5%) were from 61 to 70 years of age group with a high percentage (59.5%) of male gender. Most (46%) of the patients were from the middle class with graduation (49%), and mostly receiving &gt;1 year (55.5%) of anticoagulant therapy as treatment. The predominant age group (71–80 years) has shown good knowledge and practice pattern significantly, (P = 0.001), and the predominant duration of anticoagulant therapy (&gt;1 year) showed very good knowledge and practice pattern significantly, (P = 0.001). Conclusion: In this study, patients on oral anticoagulant therapy had limited knowledge of a good practicing pattern. More effective strategies focusing on patient knowledge and practicing patterns need to be implemented to optimize oral anticoagulant medication, improve patient outcomes, and reduce associated side effects.

Obesity as a Risk Factor for Venous Thromboembolism Recurrence: A Systematic Review.

Background and Objectives: Venous thromboembolism (VTE) encompasses Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE). The duration of anticoagulant therapy following a VTE event partly relies on the risk of recurrent VTE which depends on the clinical setting where VTE occurred and the VTE risk factors present. Obesity is considered a minor risk factor and studies in the literature have provided conflicting results on whether obesity influences the development of recurrences. The aim of the present study is to assess the effect of obesity on VTE recurrence in patients that suffered from a previous VTE event. Materials and Methods: We conducted systematic research for English language studies in Medline, Scopus and ProQuest databases in order to identify publications that assess the risk of VTE recurrence in obesity. Inclusion criteria were: 1. Diagnosis of VTE, 2. Definition of obesity as a body mass index ≥30 kg/m2, 3. Report of the risk of obesity on VTE recurrence, 4. Adult human population. We did not include case reports, review studies or studies that assessed other forms of thrombosis and/or used other definitions of obesity. We used the Newcastle-Ottawa scale to address the quality of the studies. Results: Twenty studies were included in the analysis, of which 11 where prospective cohort studies, 6 were retrospective cohort studies, 1 was a cross-sectional study, and 2 were post-hoc analysis of randomized clinical trials. Obesity was significantly associated with recurrences in 9 studies and in 3 of them the association was significant only in females. Conclusions: There is heterogeneity between the studies both in their design and results, therefore the effect of obesity on VTE recurrence cannot be adequately estimated. Future randomized clinical studies with appropriately selected population are needed in order to streamline the effect of obesity on VTE recurrence.

The Resolution Rate of Pulmonary Embolism on CT Pulmonary Angiography: a Prospective Study

PurposeTo prospectively assess the rate of clot resolution from CT pulmonary angiography (CTPA) in patients with acute pulmonary embolism (PE). Materials and MethodsThis prospective cohort study included 290 patients (136 men, 154 women; mean age, 51.9 years) with acute PE. All patients had a CTPA at the presentation and had at least one follow-up within 6 months (mean 72.7 days). Sixty-four percent of patients had follow-up scans for research purposes within a pre-determined period (between 28 and 184 days; mean, 78.27 days) and 36 % had (between 2 and 184 days; mean, 62.78 days) for a clinical indication. The volume of each clot was measured using a semi-automated quantification program. The resolution rate was evaluated by interval-censored analysis. ResultsThe overall estimated probability of complete resolution was 42 % at 7 days, 56 % at 10 days, and 71 % at 45 days. Achieving complete resolution was significantly faster in patients with peripheral clots (HR: 1.78; CI: 1.05–3.03, p = 0.032) but slower in patients with consolidation and history of venous thromboembolism (VTE), (HR: 0.37; CI: 0.18–0.79, p = 0.01 and HR: 0.57; CI: 0.35–0.91, p = 0.019, respectively). Although the patients with cancer showed a faster resolution rate (HR: 1.67; CI: 1.05–2.68, p = 0.032), the mortality rate was significantly higher than non-cancer patients. ConclusionThe resolution rate of clot burden in acute PE was associated with patients' clinical presentation variables and CTPA imaging biomarkers. This information may be incorporated into designing a prediction rule and determining the appropriate duration of anticoagulation therapy in patients with acute PE.

Uterine fibroids and the problem of deep vein thrombosis of the lower extremities. View of a vascular specialist and hematologist

The article provides clinical data and an algorithm for the management of patients with symptomatic uterine fibroids complicated by metrorrhagia and venous thrombotic events.Objective: to improve the treatment of patients with uterine fibroids complicated by abnormal menstrual bleeding, anemia and venous thrombotic events due to the implementation of the developed algorithm for diagnosis and treatment.Materials and methods. The study included 15 patients aged 32–49 years with a diagnosis of uterine fibroids with menorrhagia and iron deficiency anemia, complicated by deep vein thrombosis of the lower extremities. Thromboembolism of small branches of the pulmonary artery was diagnosed in 5 (30%) of these patients.The examination algorithm included general clinical tests (general blood and urine analysis, biochemical blood analysis, coagulogram), evaluation of the D-dimer, soluble fibrin monomer complexes, ultrasound of the pelvic organs, ultrasound duplex scanning of the veins of lower extremities, electrocardiography, echocardiography, multispiral computed tomography of chest. All patients underwent endometrial biopsy to exclude oncological pathology.The proposed treatment included: uterine artery embolization to stop bleeding, correction of hemostatic parameters, and anticoagulant therapy of venous thrombotic events after stopping bleeding.Results. Bleeding was stopped in all 100% of patients after endovascular uterine artery embolization. The duration of anticoagulant therapy depended on the causes of venous thrombosis and was at least 3–6 months; it was extended for more than 6 months if there were concomitant risk factors.Conclusions. Uterine artery embolization allows quickly and reliably stopping bleeding and immediately starting adequate anticoagulant therapy for venous thrombotic events.

A Patient with Sickle Cell Disease and Recurrent Venous Thromboembolism after Renal Transplantation

Venous thromboembolism (VTE) is a life-threatening complication, especially in case of recurrence. The appropriate duration of anticoagulant treatment following the first event is crucial. Risk factors that increase the risk of recurrence of VTE are many, and include medications, kidney disease, renal transplantation (RT), and a diagnosis of sickle cell disease (SCD). There are currently no guidelines that define the duration of anticoagulant therapy after the first event in a patient with RT. We report a case of recurring episodes of VTE after RT in a SCD patient. Our case suggests that the use of a long-term anticoagulant treatment may be recommended in patients with SCD and RT after the first event of VTE.

D-dimer: old dogmas, new (COVID-19) tricks.

D-dimer is a fibrin degradation product encompassing multiple cross-linked D domains and/or E domains present in the original fibrinogen molecule, whose generation is only theoretically possible when hemostasis and fibrinolysis pathways are concomitantly activated. D-dimer measurement has now become a pillar in the diagnosis/exclusion and prognostication of venous thromboembolism (VTE) and disseminated intravascular coagulation (DIC), when incorporated into validated clinical algorithms and especially using age-adjusted diagnostic thresholds. Although emerging evidence is also supporting its use for predicting the duration of anticoagulant therapy in certain categories of patients, the spectrum of clinical applications is constantly expanding beyond traditional thrombotic pathologies to the diagnosis of acute aortic dissection, acute intestinal ischemia and cerebral venous thrombosis among others, embracing also clinical management of coronavirus disease 2019 (COVID-19). Recent findings attest that D-dimer elevations are commonplace in patients with severe acute respiratory syndrome (SARS-CoV-2) infection (especially in those with thrombosis), its value predicts the clinical severity (up to death) of COVID-19 and remains more frequently increased in COVID-19 patients with post-discharge clinical sequelae. Further, D-dimer-based anticoagulant escalation may be associated with a lower risk of death in patients with severe SARS-CoV-2 infection and, finally, D-dimer elevation post-COVID-19 vaccination mirrors an increased risk of developing vaccine-induced thrombocytopenia and thrombosis (VITT).

Duration of Anticoagulation Therapy in Patients with Genetic Inherited Thrombophilia.

Background: Genetic factors play an important role in deep vein thrombosis (DVT). The duration of anticoagulation therapy in patients with verified genetic inheritance and previous events of DVT is still questionable. Case reports: We present three cases of siblings (two brothers and one sister) with verified Venous thromboembolism (VTE) and genetic inheritance. The first case is a 33 y.o. male who was admitted with bilateral massive pulmonary thromboembolism and DVT of the right femoral vein. He had an episode of DVT 4 years ago. Fibrinolytic therapy was introduced immediately. Afterwards, unfractionated heparin was introduced, and then switched to enoxaparin and acenocoumarol. Because of inappropriate INR, it was switched then to rivaroxaban. The imaging methods showed significant improvement, and the patient was discharged from the hospital with rivaroxaban at 2x15 mg/day for another 2 weeks and was instructed to continue 20 mg/day until his next control. In the meantime, the second case, a 36 y.o. male, brother to the first patient, came with vein thrombosis of vena saphena magna of the left leg. Treatment with Acenocoumarol was started and continued for 2 years until complete resolution of the thrombi, and then it was changed to Aspirin. The third case is the sister of the first 2 cases, a 38 y.o female with symptoms and findings almost similar to those in the second case. She was treated with Acenocoumarol for 6 months. Doppler ultrasound showed complete resolution of the thrombosis and anticoagulation therapy was stopped. Genetic investigations for mutation showed presence of homozygous gene mutation for Prothrombin (PTB G20210A) in the first patient, his brother (the second case) was compound heterozygote for PTB and for MTHFR C677T, and his sister (third case) was heterozygous only for the PTB mutation. According to the clinical (recurrent unprovoked DVT with thromboembolic complications) and genetic testing (homozygous gene mutation for PTB) in the first patient, we decided to continue the secondary thromboprophylaxis with rivaroxaban 10 mg/day indefinitely. Conclusion: Testing for genetically inherited thrombophilia should be included in the risk assessment for recurrence, and performed in all patients under 50 y.o. who have a first, non-provoked episode of thrombosis, in order to determine the duration of anticoagulation therapy.

P1695: CEREBRAL VENOUS THROMBOSIS AND ANTITHROMBOTIC THERAPY: A SYSTEMATIC REVIEW

Background: Cerebral venous thrombosis (CVT) is a cause of stroke especially in the young. The anticoagulant treatment remains controversial as it prevents neurological deterioration, new venous infarcts and death but there is a risk of bleeding complications Aims: The aim of the study was to systematically review the available studies on the efficacy and safety of anticoagulant therapy in CVT Methods: A literature search was performed (PubMed) by a combination of the terms: 1. cerebral vein thrombosis 2. cerebral venous thrombosis 3. antithrombotic therapy 4. anticoagulant therapy 5. heparin 6. warfarin 7. VKA 8. DOAC. The references of the studies were checked to obtain additional studies. The search included studies: a) related to humans b) in English and c) period:1991-2021. The following data were extracted: study characteristics (year of publication, country, study-type, sample size), demographic characteristics, type/dose of anticoagulant therapy, median follow-up, major bleeding complications, other complications during follow-up. The inclusion criteria were: 1) CVT confirmed by imaging (angiography,CT,MRI,MRV) 2) any type of anticoagulation 3) sample size>5 & 4) age>16 years Results: 25 studies were included with a total number of 2320 patients. The percentage of female patients was 70%. The age ranged 16-86 years. A total of 6 RCT, 9 prospective observational studies, 9 retrospective observational studies and 1 ambidirectional observational study were detected. Based on the limited data the anticoagulant therapy appears safe and effective, as in the acute phase it improves the clinical outcome. It is recommended that patients with acute CVT are treated with heparin. It is not contraindicated even in hemorrhagic infarcts but should be used with caution in extensive hemorrhagic infarcts, in-depth localization of the infarct and coma. LMWH appears to be associated with better outcome and fewer new intracranial hemorrhages than UFH. There is no study evaluating the role of antiplatelets. There are also insufficient data on the optimal duration of anticoagulation therapy. The use of DOAC is not recommended for the treatment of CVT, especially in the acute phase, due to the poor available evidence. Nevertheless, the limited data on the use of DOAC in the treatment of CVT imply adequate safety and efficacy. There is no study comparing different DOAC for CVT treatment. There are also insufficient data to support the use of thrombolysis in patients with CVT, as only case-reports and patient-series have been published. There is only 1 RCT in which “high-risk” patients were randomized to intravascular thrombolysis or heparin-controlled treatment. According to the European Guideline for the diagnosis and management of CVT it is not possible to provide recommendation for thrombolysis. It is suggested though not to use thrombolysis in patients with acute CVT with a low risk of poor outcome. The present systematic review highlights the lack of adequate data on optimal anticoagulation therapy in CVT Summary/Conclusion: Anticoagulant therapy for CVT appears to be safe and effective. It is recommended that patients with acute CVT are treated with heparin even cases with bleeding elements at diagnosis. LMWH appears to be associated with better outcomes and fewer new intracranial hemorrhages. The position of DOACs is an object of future research. Thrombolysis in CVT should be reserved for high-risk patients. Given the low incidence of the disease the cooperation of centers at international level is necessary. The subject of anticoagulant therapy in the treatment of CVT remains open for further research