Early Thrombosis Research Articles

The balance of thrombosis and hemorrhage in STEMI patients with or without associated cardiac arrest: An observational study

BackgroundData is scarce on hemorrhagic and thrombotic complications in patients with ST-elevation myocardial infarction (STEMI) associated with out-of-hospital cardiac arrest (OHCA). MethodsThis is a monocentric, retrospective study conducted from January 2012 to December 2017 in a tertiary university hospital, which serves as a cardiac arrest center for a large urban area. Over the study period, all consecutive patients who were treated with stent implantation for STEMI with or without OHCA were included. Baseline characteristics, treatments, hemorrhagic and thrombotic events were compared between STEMI patients with and without OHCA. Univariate and multivariate analysis were performed in order to identify predictors of 30-day mortality, occurrence of major bleeding (MB), and early stent thrombosis (ST). ResultsA total of 549 patients treated for STEMI without OHCA and 146 patients for STEMI with OHCA were included. The incidence of definite ST and MB after coronary angioplasty was significantly higher in patients with OHCA (2.6% vs. 7.5%, p = 0.004 and 3.3% vs. 19.2%, p < 0.001, respectively). Independent predictors of MB in OHCA patients were anticoagulation therapy (HR = 3.11, 95%CI [1.22–7.98], p = 0.02) and the use of glycoprotein IIb/IIIa inhibitors (HR = 4.16, 95%CI [1.61–10.79], p = 0.003). Independent predictors of mortality in OHCA patients were age (HR = 1.05, 95%CI [1.02–1.09], p = 0.004) and ST (HR = 5.62, 95%CI [1.61–19.65], p = 0.007, with a protective effect of new anti-P2Y12 treatments (HR = 0.20, 95%CI [0.08-0.46], p < 0.001). ConclusionPatients treated for STEMI associated with OHCA are at higher-risk of ST and MB than those who did not experience cardiac arrest. In this subset of patients, prospective studies are needed to better evaluate the balance of thrombosis and hemorrhage.

Endovascular treatment of aorto-hepatic bypass thrombosis following liver transplantation

Hepatic artery thrombosis is the most common vascular complication after liver transplantation. Early thrombosis is treated by surgical revascularization; if not feasible, there is need for urgent retransplantation. Late thrombosis is diagnosed mostly when clinical symptoms or graft dysfunction are present, in which case the only possible therapy is retransplantation. We present acase of ayoung patient with late thrombosis of an aorto-hepatic bypass, in whom we successfully used thrombolytic therapy with stent-graft placement.

Clinical value of digital subtraction angiography and contrast-enhanced ultrasound in evaluating early hepatic artery thrombosis after liver transplantation

Clinical value of digital subtraction angiography and contrast-enhanced ultrasound in evaluating early hepatic artery thrombosis after liver transplantation

2224 A Rare Complication of Post-TIPS Related Acute Cholecystitis

INTRODUCTION: Amongst the well documented TIPS-related biliary complications, there has been no reported case of acute cholecystitis. Multiple multicenter RCT comparing TIPS to large volume paracentesis reported better control of ascites, lower diuretic doses or cessation of diuretics in approximately 75% of the patients. Biliary related complications include biliary venous fistulas, biloma or biliary occlusion secondary to biliary compression. This may be the first reported case of Post TIPS acute cholecystitis. CASE DESCRIPTION/METHODS: 67-year-old white male with end-stage NASH cirrhosis was hospitalized 6 months ago for diuretic-resistant ascites. Prior to admission, he has required weekly large volume paracentesis. While hospitalized, he underwent large-volume paracentesis and was treated for acute urinary tract infection. TIPS was placed two weeks post discharged and ascites improved. Three days later while undergoing further evaluation, a liver ultrasound showed gall bladder wall thickening and gall stones, suggestive of acute cholecystitis with cholelithiasis. He subsequently developed severe pancytopenia and worsening liver function test. A percutaneous cholecystostomy tube was placed for gall bladder decompression along with a 14-day course of IV antibiotics. He later developed Choledocholithiasis and required ERCP and cholangioscopy. Multiple stones were extracted from the bile duct and complete fibrosis of the cystic duct was noted. The patient required multiple hospitalizations since then, frequent paracentesis and treatment for SBP. He recently underwent OLT with cholecystectomy which was technically challenging. DISCUSSION: TIPS insertion has been established as an effective second-line treatment for refractory ascites. There are 3 documented category of TIPS complications; technical, portosystemic and unique shunt related but no known reported case of acute cholecystitis. Hepatic encephalopathy occurs in approximately 30% of patients, early thrombosis or delayed shunt stenosis occurred in 22- 50% of patients prior to the development of polytetrafluoroethylene-covered stents. The technical intricacy of this intervention poses a potential risk, and morbidity rates as high as 20%. A broad understanding of the uncommon and unique complications can potentially decrease post-op-related complications especially in a patient undergoing OLT It is necessary for clinicians who perform this procedure to be aware of the clinical spectrum of TIPS-related complications and their management.

Analysis of Central Venous Access Device (CVAD) Complications in the Setting of Concomitant Surgical Procedures: Is Early Venous Thrombosis a Risk Factor for CVAD Infection?

Analysis of Central Venous Access Device (CVAD) Complications in the Setting of Concomitant Surgical Procedures: Is Early Venous Thrombosis a Risk Factor for CVAD Infection?

P6384Thrombotic-hemorrhagic balance evaluation in STEMI patients with or without associated cardiac arrest: an observational study

Abstract Background Data is scarce on hemorrhagic and thrombotic complications in patients with ST-elevation myocardial infarction (STEMI) associated with out-of-hospital cardiac arrest (OHCA). Purpose We sought to evaluate the difference in the thrombotic-hemorrhagic balance in STEMI patients with or without associated cardiac arrest. Methods This is a monocentric, retrospective study conducted from January 2012 to December 2017. Over the study period, all consecutive patients who were treated for STEMI with our without OHCA were included. Baseline characteristics, treatments, haemorrhagic and thrombotic events were compared between STEMI patients associated or not with OHCA. Univariate and multivariate analysis were performed to identify predictors of 30-day mortality, occurrence of major bleeding, defined by BARC score ≥3 and early stent thrombosis. Results A total of 549 patients treated for STEMI and 146 patients for STEMI associated with OHCA were included. The incidence of stent thrombosis and major bleeding after coronary angioplasty in patients treated for STEMI was significantly higher when associated with OHCA (2.7% vs. 12.3%, p=0.04 and 3.3% vs. 19.2%, p&lt;0.001, respectively). Independent predictors of major bleeding in OHCA patients were effective anticoagulation (HR=3.11, 95% CI [1.22–7.98], p=0.02) and the use of glycoprotein IIb/IIIa inhibitors (HR=4.16, 95% CI [1.61–10.79], p=0.003). Independent predictors of mortality in STEMI associated with OHCA were age (HR=1.05, 95% CI [1.02–1.09], p=0.004) and stent thrombosis (HR=5.62, 95% CI [1.61–19.65], p=0.007, with a protective effect of new anti-P2Y12 treatments (HR=0.20, 95% CI [0.08–0.46], p&lt;0.001). Clinical outcomes at 30 days follow-up Conclusion Patients treated for STEMI associated with OHCA are at higher-risk of stent thrombosis and bleeding than those who did not experience cardiac arrest. The use of effective anticoagulation and glycoprotein IIb/IIIa inhibitors contributes to increase bleeding complications. In this subset of patients, prospective studies are needed to better evaluate thrombotic and haemorrhagic balance.

Clinical outcomes of long stenting in the drug-eluting stent era: patient-level pooled analysis from the GRAND-DES registry.

We aimed to understand the association between stent length and clinical outcomes after percutaneous coronary intervention (PCI) using newer-generation drug-eluting stents (DES). We analysed 9,217 patients who underwent stenting for a single lesion from the GRAND-DES registry, a patient-level pooled registry including five Korean multicentre DES registries. The median follow-up duration was 730 days (interquartile range 708 to 752 days). A total of 8,035 patients were classified into the short stenting group (≤40 mm), and 1,182 into the long stenting group (>40 mm). The primary endpoint was target lesion failure (TLF). Long stenting (>40 mm) was significantly associated with higher TLF (IPTW adjusted HR 1.88, 95% CI: 1.67-2.13; p<0.001), and definite or probable stent thrombosis (IPTW adjusted HR 2.20, 95% CI: 1.51-3.20; p<0.001). In the landmark analysis, the incidence of TLF was significantly higher with long stenting during the first 30 days after PCI (log-rank p=0.001) and also after 30 days (log-rank p<0.001). Long stenting was associated with a higher risk of early stent thrombosis (log-rank p=0.001), but not with that of late stent thrombosis (log-rank p=0.887). In the contemporary second-generation DES era, stenting longer than 40 mm continues to be associated with less favourable clinical outcomes such as TLF and stent thrombosis.

Impact of Staged Vascular Management on Limb Outcomes in Wartime Femoropopliteal Arterial Injury

By necessity, wartime arterial injuries undergo staged management. Initial procedures may occur at a forward surgical team (role 2), where temporary shunts can be placed before transfer to a larger field hospital (role 3) for definitive reconstruction. Our objective was to evaluate the impact of staging femoropopliteal injury care on limb outcomes. A military vascular injury database was queried for Iraq/Afghanistan casualties with femoropopliteal arterial injuries undergoing attempted reconstruction (2004-2012). Cases were grouped by initial arterial management: shunt placed at role 2 (R2SHUNT), reconstruction at role 2 (R2RECON), and initial management at role 3 (R3MGT). The primary outcome was limb salvage; secondary outcomes were limb-specific complications. Descriptive and intergroup comparative statistics were performed with significance defined at P≤0.05. Of 257 cases, all but 4 had definitive reconstruction before evacuation to Germany (median, 2days): 46 R2SHUNT, 84 R2RECON, and 127 R3MGT; median Mangled Extremity Severity Score was 6 for all groups. R2SHUNT had median extremity Abbreviated Injury Scale--vascular of 4 (other groups, 3; P<0.05) and was more likely to have concomitant venous injury and to undergo fasciotomy. Shunts were used for 5±3hr. About 24% of R2RECON repairs were revised at role 3. Limb salvage rate of 80% was similar between groups, and 62% of amputations performed within 48hr of injury. Rates of limb and composite graft complications were similar between groups. Thrombosis was more common in R2SHUNT (22%) than R2RECONST (6%) or R3MGT (12%) (P=0.03). Late (>48 hr) thrombosis rates were similar, whereas 60% of R2SHUNT thromboses occurred on day of injury (P=0.003 vs. 25% and 0%). Staged femoropopliteal injury care is associated with similar limb salvage to initial role 3 management. Early thrombosis is likely because of shunt failure but does not lead to limb loss. Current military practice guidelines are appropriate and may inform civilian vascular injury management protocols.

Effectiveness and Safety of Ultrasound Guided Lower Extremity Nerve Blockade in Infragenicular Bypass Grafting for High Risk Patients With Chronic Limb Threatening Ischaemia

Surgical revascularisation to accomplish limb salvage remains preferable in some patients with chronic limb threatening ischaemia (CLTI). The aim of this study was to evaluate the effectiveness and safety of ultrasound guided lower extremity nerve blockade (UGNB) in infragenicular bypass surgery (IGBS). This was a single centre, retrospective clinical study. Fifty-nine patients with CLTI (67 limbs) who underwent IGBS under UGNB (femoral and sciatic nerve blockade) at Asahikawa Medical University between January 2012 and December 2017 were compared with patients with CLTI (137 limbs) who underwent IGBS under general anaesthesia (GA) over the same period. Propensity score matching based on pre-operative comorbidities was used to minimise background differences of the two groups. Fifty-six pairs of CLTIs were matched and analysed (55% dialysis dependent). Procedure duration was similar between the two groups, but intraoperative catecholamine index and intravenous fluid volume were lower with UGNB compared with GA (2.9 ± 4.6 vs. 5.9 ± 6.5; p < .01 and 1831 ± 990 vs. 2335 ± 931 mL; p < .01, respectively). The mean arterial blood pressure during induction of anaesthesia was significantly decreased with GA. Post-operatively, the time period to resume a clear liquid and solid food diet was significantly shorter with UGNB (P < 0.01 for both outcome measures). Intravenous fluid volume was significanlty lower, while cardiac complications and delirium, based on the NEECHAM confusion scale, occurred significantly less often with UGNB than GA. These significant differences show advantages of UGNB compared to GA. No mortality or major amputations were observed in either group. Early graft thrombosis was observed in five limbs (8.9%) with UGNB and in four limbs with GA (7.1%) (p = .73). UGNB has advantages for intra- and post-operative management and could be a useful method to prevent peri-operative complications for high risk patients with CLTI. To ensure the effectiveness of UGNB for IGBS for future indications, a randomised study is required.

Safety of coiling with stent placement for the treatment of ruptured wide-necked intracranial aneurysms: a contemporary cohort study in a high-volume center after improvement of skills and strategy.

The authors compared the contemporary perioperative procedure-related complications between coiling with stent placement and coiling without stent placement for acutely ruptured aneurysms treated in a single center after improvement of interventional skills and strategy. In an institutional review board-approved protocol, 133 patients who underwent coiling with stent placement and 289 patients who underwent coiling without stent placement from January 2012 to December 2014 were consecutively reviewed retrospectively. Baseline characteristics, procedure-related complications and mortality rate, angiographic follow-up results, and clinical outcomes were compared between the two groups. Univariate analysis and logistic regression analysis were performed to determine the association of procedure-related complications of coiling with stent placement with potential risk factors. The coiling/stent group and coiling/no-stent group were statistically comparable with respect to all baseline characteristics except for aneurysm location (p < 0.001) and parent artery configuration (p = 0.024). The immediate embolization results and clinical outcomes between the two groups showed no significant differences (p = 0.807 and p = 0.611, respectively). The angiographic follow-up results of the coiling in stent group showed a significant higher occlusion rate and lower recurrence rate compared with the coiling/no-stent group (82.5% vs 66.7%, 3.5% vs 14.5%, p = 0.007). Procedure-related intraoperative rupture and thrombosis, postoperative early rebleeding and thrombosis, and external ventricular drainage-related hemorrhagic event occurred in 3.0% (4 of 133), 2.3% (3 of 133), 1.5% (2 of 133), 0.7% (1 of 133), and 0.8% (1 of 133) of the coiling/stent group compared with 1.0% (3 of 289), 1.4% (4 of 289), 1.4% (4 of 289), and 0.7% (2 of 289) of the coiling/no-stent group, respectively (p = 0.288, p = 0.810, p = 1.000, p = 0.315, and p = 1.000, respectively). One patient presented with coil protrusion in the group of coiling without stent. The procedure-related mortality was 1.5% (2 of 133) in the coiling/stent group and 0.7% in the coiling/no-stent group (p = 0.796). Multivariable analysis showed no significant predictors for the total perioperative procedure-related complications, hemorrhagic complications, or ischemic complications. The perioperative procedure-related complications and mortality rate did not differ significantly between the coiling/stent group and the coiling/no-stent group for patients with acutely ruptured aneurysms. Considering the better angiographic follow-up results, coiling with stent placement might be a feasible, safe, and promising option for treatment in the acute phase of selected wide-necked ruptured intracranial aneurysms.

Inconsistent Harmonic Peaks in Patients with Continuous Left Ventricular Assist Devices at Baseline

Introduction Despite improvements in continuous left ventricular assist devices (LVADs), 8-11% of patients annually experience thrombosis. Quantitative acoustic analysis of LVADs has recently been investigated as a novel method of early thrombosis detection. Previous studies have shown the existence of peaks in sound amplitude at expected harmonics based on VAD speed, and changes in amplitude with thrombosis. However prior to utilizing this method to detect thrombosis in patients, it is important to establish a baseline of acoustics in VAD patients with no known thrombosis. Hypothesis In patients with HeartMateII (HMII) and HeartMateIII (HMIII) LVADs, with no clinical indication of thrombosis, there will be consistent characteristic peaks at the first 4 harmonics. Methods 19 HMII patients and 3 HMIII patients were recorded at the heart apex for 6-8 seconds using 3M™ Littmann® Electronic Stethoscope Model 3200. Patients were recorded at least once over 2 years, with 4 HMII and 2 HMIII patients recorded 2-3 times. Software used includes 3M™ Littmann® StethAssist™ to upload sound files, Audacity 2.1.2 to generate acoustic spectrum data via Fourier transform, and Microsoft Excel to visualize sound amplitude peaks in the frequency spectrum. Expected harmonic frequencies (Hλ) based on LVAD speed were calculated with the equation: Hλ = (n*RPM)/60. Patient demographics, VAD parameters, and laboratory studies were collected from the electronic medical record. Acoustics and patient data were analyzed, focusing on the presence or absence of the first four harmonics. Results In all HMII recordings, peaks were present at the 1st and 3rd harmonics. In 8 out of 19 HMII patients, all peaks 1-4 were present (Group 1). In 11 out of 19 HMII patients, either the 2nd +/- 4th peaks were missing (Group 2). Between the two groups there was no significant difference in vital signs, VAD parameters or labs. In Group 2, 3 out of 4 patients are missing the same harmonic peaks on subsequent recordings. Only one patient in Group 2 was inconsistent in peaks missing on subsequent recordings. In all HMIII recordings peaks at the 1st, 2nd, and 4rd harmonics were present. Four out of five recordings showed an extra peak between the 2nd and 3rd harmonics. The 3rd harmonic was present in only one recording and had a smaller sound amplitude than other peaks. Conclusions Although other studies have shown data with consistent peaks at all expected 1-4th harmonics, our study did not find this to be true. In HMII devices, it appears 1st and 3rd harmonics are most consistent across patients, while the 1st, 2nd, and 4th harmonics are most consistent in HMIII devices. Individual patients remain relatively consistent in harmonics missing, and therefore baseline acoustic spectrums may be patient specific similar to other VAD parameters. Consequentially, it may be necessary to determine a patient's own baseline acoustics and use the deviation as an indicator of possible pathology or significant physiologic change.

Temporal distribution and biological determinants of thrombotic events after interventions for dialysis vascular access

Endovascular therapy is the principal therapy for haemodialysis vascular access dysfunction. Nonetheless, the incidence and determinants of post-intervention thrombotic events are unclear. This prospective cohort study evaluated the incidence and timing of thrombotic events after endovascular therapy and analysed the clinical, angiographic, and biological determinants of thrombosis. Of the 236 patients enrolled, 91 experienced post-intervention thrombotic events within 1 year. The 1-year thrombosis-free patency was 28% for thrombosed accesses, 53% for non-thrombosed grafts, and 78% for non-thrombosed fistulas. Forty-one of the 91 thrombotic events (45%) occurred within 3 months post-intervention. In the univariate analysis, early thrombosis was associated with longer haemodialysis duration (hazard ratio [HR], 1.01; 95% confidence interval [CI], 1.01–1.02), graft access (HR, 7.69; 95% CI, 3.33–20.0), multiple stenoses (HR, 2.69; 95% CI, 1.36–5.37), and high indoxyl sulphate (IS) levels (HR, 1.55; 95% CI, 1.32–1.82). Late thrombosis was associated with diabetes (HR, 1.89; 95% CI, 1.01–3.57), cardiovascular disease (HR, 2.38; 95% CI, 1.27–4.54), and endothelial progenitor cell counts (HR, 0.97; 95% CI, 0.93–0.99). After multivariate adjustment, high IS was the major predisposing factor for early post-intervention thrombosis (HR, 1.41; 95% CI, 1.18–1.69). Our findings suggest that measures to decrease IS could target the most critical period of thrombosis.

Analysis of central venous access injuries from claims to the Swedish Patient Insurance Company 2009-2017.

Insertion and use of central venous access devices (CVADs) can be associated with serious adverse events. The incidence is generally low but considering the vast use of CVADs the consequences can, from a patient safety and health economics perspective, be severe. No exact knowledge exists of number of catheters or complications in Sweden, as there is currently no comprehensive registry. The aim was to analyse injuries reported to the Swedish National Patient Insurance Company (Löf) within 7days after insertion or removal of a CVAD. A retrospective analysis of all injuries filed in the period 2009-2017 was performed, evaluating patient data, type of catheter, insertion technique and type of injury. If the injury was deemed avoidable by Löf, degree of disability and mortality was registered. A total of 87 claims of injuries were found of which 36 (41%) were assessed as avoidable. The most common injuries were: bleeding (18%), early infection (17%), pneumothorax (17%) and early thrombosis (15%). No patients died of their injuries, but 17 of 36 suffered permanent disability of varying degrees. Ultrasound-guided insertion was used in 19% of the cases. In Sweden, few injuries related to CVAD use are reported to Löf. About 40% of filed claims were categorized as having an avoidable injury and therefore eligible for compensation. About half of the compensated patients suffered a permanent disability. The results indicate underreporting of CVC-related injuries in Sweden during the studied time-period.

Managing Intracranial Hemorrhage in Patients with a Durable Continuous Flow Left Ventricular Assist Device

Background&#x0D; While intracranial hemorrhage (ICH) is a known complication of left ventricular assist device (LVAD) support, and is associated with high morbidity and mortality, optimal care pathways have neither been elucidated nor reported. We describe management of LVAD patients following ICH, with a focus on anticoagulation, operative interventions, care team designation, complications, and outcomes.&#x0D; Methods&#x0D; We retrospectively reviewed all durable continuous-flow LVAD implantations at our academic medical center from January 2007 to July 2018. Patients who experienced ICH after LVAD were identified. We defined baseline and ICH characteristics, medical and surgical interventions, care teams, and outcomes including death, device thrombosis, ischemic stroke, and hemorrhage expansion.&#x0D; Results&#x0D; A total of 321 patients underwent LVAD implantation during the study period, and 27 (8%) developed ICH (17 intraparenchymal, 7 subdural, 2 subarachnoid, 1 intraventricular) while on support. Twenty-five were anticoagulated at onset of bleed. Of those, 13 were managed with immediate cessation of anticoagulation and administration of reversal products (Group A). Group A had a median of 6 days off anticoagulation and 60 days of follow up with 1 patient (8%) developing device thrombosis at day 8, 1 (8%) developing subsequent ischemic stroke at day 14, and 4 (31%) with ICH expansion. Seven patients had anticoagulation stopped at onset of bleed without administration of reversal products (Group B). With a median of 2 days off anticoagulation and 2 days of follow up, no patients in Group B developed ischemic stroke or device thrombosis while 1 (14%) had ICH expansion. Five patients had anticoagulation continued at onset of bleed (Group C) with a median follow up of 330 days. One (20%) developed device thrombosis at day 5 while 2 (40%) developed ICH expansion. Four patients with subdural hemorrhage underwent Burr hole drainage with all 4 surviving to discharge. Two patients with intraparenchymal hemorrhage underwent open craniotomy with neither surviving to discharge. An interdisciplinary discussion occurred in all cases. Following ICH, only one-third of patients in the study survived to 6 months.&#x0D; Conclusion&#x0D; LVAD patients who experience an ICH have variable outcomes. Their care is multidisciplinary and can involve operative intervention. The discontinuation and reversal of anticoagulation is generally well-tolerated, with a low risk for early device thrombosis. Like for many hemorrhagic complications of LVADs, ICH often persists or worsens. Additional investigation is needed to elucidate the most optimal management strategies.

Higher Rate of Early Revision Following Primary Total Knee Arthroplasty in Patients Under Age 55: A Cautionary Tale

BackgroundThere has been an increased number of total knee arthroplasties (TKAs) performed in young and active patients. Although improved materials have decreased the likelihood of early catastrophic wear, concerns remain with the performance and survivorship of TKA implants in this patient population. The purpose this study is to evaluate perioperative complications, patient-reported outcomes, and implant survivorship of TKAs performed in patients under age 55. MethodsWe retrospectively reviewed 4259 primary TKAs performed over a 4-year period. There were 741 TKAs in patients under age 55. The primary outcome of interest was rate of revision at 30 days, 1, 2, and 5-year time points. Secondary outcomes included postoperative transfusion rate, length of stay, rate of deep vein thrombosis/pulmonary embolism, need for manipulation under anesthesia, readmission and reoperation within 30 days, as well as patient-reported outcomes. ResultsThere were 3518 patients over 55 years and 741 patients under 55 years. Overall, 175 patients required revision (4.1%). Patients under 55 years had significantly higher cumulative revision rate at 1 (3.4% vs 1.8%, P < .001), 2 (5.0% vs 2.4%, P < .001), and 5 years (7.3% vs 3.7%, P < .001). Patients under 55 years had a higher rate of early reoperation. Patients over 55 years required more transfusions and suffered a higher rate of early deep vein thrombosis. Patients over 55 years had significantly greater improvements in Patient Reported Outcome Measurement Information System Global 10 Physical scores at 6 months postoperatively compared to patients under 55 years. ConclusionsDespite improvements in TKA implants, young and active patients remained at higher risk of early revision compared to older patients. The data should be used to counsel young prospective TKA patients about the early risk of reoperation and non–wear-related complications.

Effectiveness and Safety of Ultrasound Guided Lower Extremity Nerve Blockade in Infragenicular Bypass Grafting for High Risk Patients With Chronic Limb Threatening Ischaemia

Surgical revascularisation to accomplish limb salvage remains preferable in some patients with chronic limb threatening ischaemia (CLTI). The aim of this study was to evaluate the effectiveness and safety of ultrasound guided lower extremity nerve blockade (UGNB) in infragenicular bypass surgery (IGBS). This was a single centre, retrospective clinical study. Fifty-nine patients with CLTI (67 limbs) who underwent IGBS under UGNB (femoral and sciatic nerve blockade) at Asahikawa Medical University between January 2012 and December 2017 were compared with patients with CLTI (137 limbs) who underwent IGBS under general anaesthesia (GA) over the same period. Propensity score matching based on pre-operative comorbidities was used to minimise background differences of the two groups. Fifty-six pairs of CLTIs were matched and analysed (55% dialysis dependent). Procedure duration was similar between the two groups, but intraoperative catecholamine index and intravenous fluid volume were lower with UGNB compared with GA (2.9±4.6 vs. 5.9±6.5; p<.01 and 1831±990 vs. 2335±931mL; p<.01, respectively). The mean arterial blood pressure during induction of anaesthesia was significantly decreased with GA. Post-operatively, the time period to resume a clear liquid and solid food diet was significantly shorter with UGNB (P<0.01 for both outcome measures). Intravenous fluid volume was significanlty lower, while cardiac complications and delirium, based on the NEECHAM confusion scale, occurred significantly less often with UGNB than GA. These significant differences show advantages of UGNB compared to GA. No mortality or major amputations were observed in either group. Early graft thrombosis was observed in five limbs (8.9%) with UGNB and in four limbs with GA (7.1%) (p=.73). UGNB has advantages for intra- and post-operative management and could be a useful method to prevent peri-operative complications for high risk patients with CLTI. To ensure the effectiveness of UGNB for IGBS for future indications, a randomised study is required.

MANAGEMENT OF ARTERIAL COMPLICATIONS AFTER LIVING DONOR LIVER TRANSPLANTATION

Background: Liver transplantation is perceived as the only curative treatment for patients with end-stage liver disease. Arterial complications are one of the most serious complications after living donor liver transplantation (LDLT).Aim of the work: To assess the different modalities of management and outcome of early and late arterial complications and to analyze the risk factors of such complications after living donor liver transplantaiton. Patients and Methods: This is a retrospective study in which 293 LDLT operations were done between 2008 and May 2017 at Ain Shams center for organ transplantation (ASCOT). After approval of Ethics committee and the research council, Ain shams universityschool of medicine, we did this retrospective cohort study that analyzed the incidence, risk factors, management and outcome of HA complications in adults and pediatrics recipients in the period from 2008 to May 2017, where patients were observed from POD 1 until the end 2017 or until death of patients. Results: In our study early arterial complications are more higher and more serious than late arterial complications. Mortality rate in patients with early complications exceeds 50%.In late complications it was 20%. Conclusion: Urgent surgical management is life saving in cases of early hepatic artery thrombosis (HAT). Arterial reconstruction is technically difficult. LD retransplant has been performed in a very small number worldwide. Emergency living donor retransplantation is life saving in cases of early (HAT). Arterial reconstruction using left gastric artery and splenic artery is feasible in LD retransplant and arterial reconstruction after HAT. Early diagnosis and surgical or radiological intervention is the corner stone to save the recipient.

Primary Failure of the Arteriovenous Fistula in Patients with Chronic Kidney Disease Stage 4/5.

BACKGROUND:An Arteriovenous fistula (AVF) is a creation of the natural blood vessels. It is a “gate of life” for the patients on hemodialysis.AIM:The study aimed to analyze the predictors for primary failure of AVF such as gender, age, number and location of AVF, and primary renal disease in patients with chronic kidney disease (CKD) stage 4/5.MATERIAL AND METHODS:The medical records of 178 created arteriovenous fistulae in patients with CKD stage 4/5, were retrospectively studied. Primary failure of AVF was defined as thrombosis or inability for cannulation of AVF within 3 months. Adequate maturation of AVF was defined as successful cannulation of AVF treatment and blood flow of > 600 ml/min.RESULTS:The mean age of the patients was 59.75 ± 14.65 years, and 65.16% (116/178) were men. Adequate maturation of AVF was achieved in 83.71% (149/178). Primary failure of AVF occurred in 16.29% (29/178) of the created fistulae, while 10.11% (18/178) had early thrombosis. The distal arteriovenous fistulae were significantly more frequently created in male patients (51 vs 18; p = 0.015). The female patients were significantly older than the male patients (63.27 vs 57.86 years; p = 0.018).CONCLUSION:Male gender was associated with better maturation of AVF. The age, number and location of AVF, and primary renal disease in patients with CKD stage 4/5 were not associated with primary failure of AVF.

221-OR: Pancreas Transplantation from Pediatric Donors: An Opportunity to Increase Donor Pool

Background: Pancreas transplants (PTx) from pediatric donors (PDs, age &amp;lt;18 years) might expose to greater technical difficulties and provide less insulin independence in the long-term due to smaller beta cells mass. Most available data on pancreas transplants from PDs relate to simultaneous pancreas-kidney transplants, whereas little is known on pancreas transplant alone (PTA) from PDs. Methods: We retrospectively analyzed perioperative surgical complications and graft survival in T1D recipients of PTA or pancreas after kidney (PAK) transplant from PDs or adult donors (ADs) between Jan 2010 and May 2018. Data were collected through electronic medical record review. Results: A total of 43 PTx recipients (35 PTA) had data available for analyses. Age at PTx was 40.0±8.3 years, T1D duration 25±10 years, 46.5% female, BMI 23±3 k/m2. Nearly half (49%) pancreas grafts were from PDs. Median donor age was 18 [IQR: 16] years (min. 2, max 45 years). Donor characteristics (age, BMI, body surface area [BSA]) significantly differed between groups (all p&amp;lt;0.05), but recipient characteristics (age at PTx, T1D duration, BMI) were similar. Median length of stay was similar in the AD and PD groups (17.5 [8.5] vs. 14 [7.0] days, p=NS). Rates of any perioperative surgical complications (55% vs. 33%), re-laparotomy (41% vs. 19%) and explanation (36% vs. 10%) were numerically lower and early graft thrombosis was significantly lower (55% vs. 10%, p&amp;lt;0.01) in the PD group. Median graft survival was numerically greater in the AD vs. the PD group (8.5 vs. 5.7 years, p=0.34). However, rejection rate was significantly higher in the PD group (4.5% vs. 52%, p&amp;lt;0.01). We found no correlation between donor characteristics (age, BMI, BSA and donor/recipient BSA ratio) and graft survival. Conclusions: PTx from PDs tended to be associated with less surgical complications vs. PTx from ADs. Graft survival was similar. Expanding selection criteria to include PDs would increase the availability of pancreas grafts and possibly improve clinical outcomes. Disclosure C. Conte: None. C. Socci: None. A. Secchi: None. P. Maffi: None.

Treating Intimal Injury to the Graft Hepatic Artery by Intraoperative Fluorescence Vascular Stenting.

Early hepatic artery (HA) thrombosis and primary graft failure contribute greatly to the mortality of patients after liver transplantation. Herein, we present the treatment of intimal injury of HA by intraoperative fluorescence vascular stenting. A sample of 471 patients receiving liver transplantations underwent arterial anastomosis. Six patients (1.3%) were found to have early HA thrombosis. Two patients had thrombi that were impenetrable with a guide wire. Intimal injury on both the graft and the donor sides of the HA was found after thrombectomy. We performed anastomosis between unhealthy graft vessels and healthy recipient vessels. Intraoperative angiography was done immediately because of the guide wire being easier to insert through a fresh thrombus, and a long endovascular stent was inserted to bypass the injured vessels. The proper HA was reconstructed under microscopy. Three days after reconstruction, an angioplasty showed no dissection, stenosis, or pseudoaneurysm of the HA. Unexpectedly, these 2 patients survived well with acceptable graft functionality, one based on a 32-month follow-up and the other based on a 2-month follow-up. Anastomosis of the intimally injured graft artery followed by immediate endovascular angioplasty with stenting to bypass the injury zone is an efficacious and tolerable procedure.