Bleeding Complications Research Articles

Prevalence and clinical characteristics of patients with brain metastases at diagnosis with advanced hepatocellular carcinoma in a retrospective registry.

540 Background: Hepatocellular carcinoma (HCC) is a cancer with poor prognosis and rising incidence. The combination of atezolizumab plus bevacizumab (A+B) prolongs survival as 1 st line therapy in advanced HCC (aHCC) but confers a rare risk of serious bleeding. HCC brain metastases (BM) have high hemorrhage rates and contraindicate the A+B regimen. Alternative immunotherapies also prolong survival without increased bleeding risk. We conducted a retrospective review of a large, diverse, cancer center registry to estimate the prevalence of and identify clinical characteristics associated with BM in aHCC. Methods: The University of California, San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center (HDFCCC) registry was queried for new cases of HCC between 2004 and 2022. AJCC stage III or IV were defined as aHCC. Cases with central nervous system (CNS) metastases (including brain as well as skull, face, or orbit as adjacent high-risk sites) at diagnosis were identified. Key clinical covariates including demographics, liver disease etiology, and symptomatology were described. Results: Among 4002 new HCC cases, 832 were classified as aHCC. 12/832 (1.4%, 95% CI: 0.8, 2.5) had synchronous BM. Key demographics are displayed in Table. 10/12 (83%) patients with BM were symptomatic, including headache (25%), neurologic deficits (67%), and/or syncope (8%). Bleeding complications and/or hemorrhagic features were reported in 17%. Conclusions: BM are rare at diagnosis with aHCC, present in only 1.4% of this registry dataset. The majority (83%) were symptomatic, suggesting that routine CNS imaging may not have clinical utility in asymptomatic patients. A high proportion with BM at diagnosis had viral etiology. Limitations of this retrospective registry analysis include potential for underdiagnosis in asymptomatic patients and incomplete data for clinical covariates. Clinical characteristics of aHCC cases with BM at diagnosis between 2004-2022 in UCSF HDFCCC Registry. Overall aHCC Cases (N=832) Cases with BM (n=12) Median age (range) (yrs.) 61 (8-92) 60 (48-65) Race/ethnicity (%)AsianBlackCaucasianHispanic (any race) 29105715 2586717 Gender (%)MaleFemale 7921 7525 Etiology (%)Viral hepatitisUnknown/negative 2971 7525 Symptomatic BM (%)HeadacheNeurologic deficitsSyncope NA 8325678 Hemorrhagic BM (%) NA 17

FRED-EPI study: Safety and efficacy of FRED/FRED Jr aneurysm treatment in current clinical practice.

Flow diversion is increasingly used as an endovascular treatment for intracranial aneurysms. FRED-EPI is a prospective, multicenter, French study, conducted to analyze the safety and efficacy of aneurysm treatment with FRED/FRED Jr (Microvention, AlisoViejo, CA, USA) in current clinical practice. Patients with intracranial aneurysms treated with FRED and FRED Jr who agreed to participate were prospectively and consecutively included in all French centers using these devices. From June 2020 to January 2022, 135 patients (110 females, 81.5%, and 25 males, 18.5%) with 154 aneurysms were included in 13 French interventional neuroradiology centers. The mean age was 53.9 ± 12.2 years (range: 20 - 77 years). Aneurysm was unruptured in 123 cases (79.9%), ruptured in 4 cases (2.6%), and recanalized in 27 cases (17.5%). Most aneurysms were small (135/154, 87.7%). Aneurysm locations were supraclinoid ICA in 83 (53.9%), cavernous and petrous ICA in 25 (16.2%), anterior cerebral artery or anterior communicating artery in 19 (12.3%), MCA in 7 (4.5%), and posterior circulation in 20 (13.0%). Three patients (2.2%) had hemorrhagic complications (1 delayed aneurysm rupture and 2 delayed remote hematoma) and 3 (2.2%) ischemic complications (2 intrastent thrombosis and 1 stroke related to atherosclerosis) leading to 1-year morbimortality of 4.4%. Complete aneurysm occlusion was reported in 105/139 aneurysms (75.5%). FRED-EPI confirms good safety of aneurysm treatment with FRED/FRED Jr in current clinical practice with 4.4% 1-year morbimortality.

Safety and Efficacy of DPMAS in Patients With Acute-on-Chronic Liver Failure Based on Different Platelet Count Levels.

To investigate the effect of different platelet (PLT) counts on the safety and efficacy of the double-plasma molecular absorption system (DPMAS) in patients with acute-on-chronic liver failure (ACLF). A total of 156 patients with ACLF receiving DPMAS were divided into the observed group (40 × 109/L ≤ PLT < 50 × 109/L) and the control group (PLT ≥ 50 × 109/L) according to PLT count level. The safety and efficacy indices of bleeding-related complications, PLT reduction rate, total bilirubin (TBIL) reduction rate, and 28-days survival rate after DPMAS were analyzed and compared between the two groups. The incidence of bleeding complications during and after DPMAS in the observed and control groups (14.3% vs. 14.9%, p = 0.922), the decline rate of PLT immediately and 24 h after treatment (0.13 vs. 0.11/0.05 vs. 0.09, p = 0.256/0.161), and the 28-days survival rate after treatment (76.2% vs. 75.4%, p = 0.923) were not significantly different. The thromboelastogram before DPMAS showed no significant difference in PLT function between the two groups (p > 0.05). Although the TBIL level of the two groups rebounded 24 h after treatment compared with immediately after treatment, it decreased significantly immediately and 24 h after treatment compared with pre-treatment levels (p < 0.05). There was no significant difference in the rate of decline of serum TBIL immediately after treatment and 24 h after treatment between the two groups (0.33 vs. 0.35/0.14 vs. 0.16, p = 0.193 and 0.653, respectively). DPMAS is safe and effective in patients with ACLF with 40 × 109/L ≤ PLT count < 50 × 109/L.

Rationale and design of the STOP-IMH randomised trial: Safety of ticagrelor monotherapy after primary percutaneous coronary intervention for ST-elevation myocardial infarction and the effect on intramyocardial haemorrhage

BackgroundTicagrelor monotherapy after 1–3 months of dual antiplatelet therapy (DAPT) has shown to be effective and safe after percutaneous coronary intervention (PCI), including in patients with an ST elevation myocardial infarction (STEMI). Direct omission of aspirin could further reduce bleeding complications and may reduce the incidence and expansion of intramyocardial haemorrhage (IMH), a frequent complication after revascularisation for a STEMI. MethodsThis multicentre open label pilot study randomises 200 STEMI patients within 24 hours after primary PCI and before the first subsequent dose of aspirin to ticagrelor monotherapy or ticagrelor plus aspirin for twelve months. As IMH is more frequently observed after an anterior STEMI, IMH and infarct size will be determined with cardiac magnetic resonance (CMR) imaging in 60 anterior STEMI patients. In this subgroup, blood samples will be analysed for biochemical outcomes. ResultsThe primary safety endpoint consists of major adverse cardiac and cerebral events, and the primary efficacy endpoint is infarct size on CMR. Secondary efficacy endpoints consist of the incidence and extent of IMH determined by CMR, and of clinical bleeding events. Other endpoints include all-cause mortality and biochemical outcomes. ConclusionThe STOP-IMH pilot study compares ticagrelor monotherapy with ticagrelor plus aspirin directly after primary PCI in 200 STEMI patients. We aim to provide a signal of safety regarding ischemic events for the direct omission of aspirin after primary PCI, and to compare the infarct size by CMR between the two treatment strategies in the first week after primary PCI.

Meta-analysis of randomized controlled trials (RCTs) to evaluate the incidence of hemorrhage and venous thromboembolism (VTE) events in patients with gastrointestinal (GI) cancers treated with fruquintinib.

118 Background: Fruquintinib is a novel cancer therapy that was recently approved by the US FDA as a third-line treatment for metastatic colorectal cancer (mCRC). It works by inhibiting the vascular endothelial growth factor receptors, that leads to blocking of angiogenesis which is essential for the tumor proliferation. Close monitoring is always crucial in order to promptly detect and manage any adverse events. This study aims to assess the risk of hemorrhagic and VTE events in patients with GI cancers treated with fruquintinib. Methods: A comprehensive literature search was conducted using MEDLINE, EMBASE, and COCHRANE databases from inception through August 12th, 2024. Phase II/III RCTs utilizing fruquintinib in GI cancers reporting hemorrhage or VTE events as an adverse event were included. Mantel-Haenszel method was used to calculate the estimated pooled risk ratio (RR) with 95% confidence interval (CI). Heterogeneity was assessed with Cochran’s Q-statistic. Random effects model was applied. Results: A total of 1872 patients were included. Data were pooled from three phase III RCTs (FRESCO, FRESCO-2, FRUTIGA) and one phase II RCT, all reporting VTE events including deep vein thrombosis and pulmonary embolism and hemorrhage. FRESCO, FRESCO-2, and the phase II trials involved patients with mCRC, comparing fruquintinib to placebo. FRUTIGA trial incorporated patients with gastric or gastroesophageal junction adenocarcinoma, comparing fruquintinib + paclitaxel to placebo + paclitaxel. High-grade hemorrhage incidence was higher in the fruquintinib arm compared to the control arm (29.00% vs 21.18%, RR 1.62; 95% CI: 1.26-2.08, P=0.0001). In the mCRC subgroup, high-grade hemorrhage rate was also higher and statistically significant in the fruquintinib arm 20.87% vs 11.22% (RR 1.84; 95% CI: 1.25-2.70; P=0.002). Incidence of any grade or high grade VTE events was neither statistically significant in GI cancer population or mCRC subgroup. Incidence of any grade VTE events in GI cancer group and mCRC subgroup was 2.74% vs 2.15% (RR, 1.23; 95% CI: 0.53-2.88; P=0.63) and 2.68% vs 1.53% (RR, 0.95; 95% CI: 0.09-9.67; P=0.97), respectively. Rate of high grade VTE events in GI cancer cohort was 1.67% vs 0.67% (RR, 1.96; 95% CI: 0.52-7.36; P=0.32), while in mCRC subgroup was 1.79% vs 0.76% (RR, 1.08; 95% CI: 0.06-19.98; P=0.96). Conclusions: This meta-analysis demonstrates that patients with GI cancers, including mCRC, treated with fruquintinib have higher incidence of high-grade hemorrhage. These findings underscore the importance of individualized risk assessment, especially for patients predisposed to hemorrhagic complications. No increased risk of VTE events was noted in patients treated with fruquintinib compared to placebo.

Antithrombotic resumption after middle meningeal artery embolization or surgery for chronic subdural hematoma: a systematic review and meta-analysis

BackgroundThe periprocedural management of antithrombotic medications in patients with chronic subdural hematoma (cSDH) after middle meningeal artery embolization (MMAE) or surgical evacuation is uncertain.MethodsA systematic review was conducted across Medline,...

The effect of sarpogrelate compared to aspirin in high- or very-high-risk diabetes for primary prevention

The benefit of aspirin in primary prevention for atherosclerotic cardiovascular diseases (ASCVD) is questionable due to bleeding complications. We analyzed the Korean National Health Insurance data to compare the efficacy and overall bleeding of sarpogrelate, an antiplatelet agent with lower bleeding risk, versus aspirin in high-/very-high-risk diabetic populations without prior ASCVD. The primary endpoint was net adverse clinical events (NACE), defined as a composite of efficacy and overall bleeding. The efficacy was a composite of all-cause death, myocardial infarction (MI) and stroke, whereas overall bleeding included intracranial hemorrhage (ICH) and gastrointestinal (GI) bleeding. A total of 10,778 high-/very-high-risk diabetic patients (9550 on aspirin, 1228 on sarpogrelate) were analyzed. After propensity score matching, sarpogrelate was linked to a lower incidence of NACE (HR:0.71; 95% CI 0.57–0.88), mainly driven by 62% reductions in overall bleeding (0.38; 0.17–0.81), a composite of 64% and 72% lower rate of GI bleeding and ICH, respectively. Additionally, there was no significant differences in MI or stroke between groups. In high- or very-high-risk diabetic patients without ASCVD, sarpogrelate use was associated with net clinical benefit mainly due to the reduction of significant reduction in overall bleeding events.

Efficacy and Safety of Mechanical Thrombectomy in Distal Medium Middle Cerebral Artery Occlusion Ischemic Stroke Patients on Low-Dose Aspirin.

Acute ischemic stroke (AIS) from distal medium vessel occlusion (DMVO) presents unique treatment challenges. Mechanical thrombectomy (MT) is emerging as a viable option for these patients, yet the role of pre-stroke aspirin treatment is unclear. This study evaluates the impact of pre-stroke low-dose aspirin on outcomes in DMVO patients undergoing MT. We conducted a multinational, multicenter, propensity score-weighted analysis within the Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy (MAD-MT) registry. Patients with AIS due to DMVO, treated with MT, were included. We compared outcomes between patients on pre-stroke low-dose aspirin (75-100 mg) and those not on antiplatelet therapy. The primary outcome was functional independence at 90 days (mRS 0-2). Secondary outcomes included excellent functional outcome at 90 days (mRS 0-1), mortality, and day-one post-MT NIHSS score. Safety outcomes focused on hemorrhagic complications, including symptomatic intracerebral hemorrhage (sICH). Among 1,354 patients, 150 were on pre-stroke low-dose aspirin. After applying Inverse Probability of Treatment Weighting (IPTW), Aspirin use was associated with significantly better functional outcomes (mRS 0-2: OR =1.89 , 95% CI, 1.14 to 3.12 ) and lower 90-day mortality (OR = 0.56, 95% CI, 0.32 to 1.00). The aspirin group had lower NIHSS scores on day one (β = -1.5, 95% CI, -2.8 to - 0.27). The sICH rate was not significantly different between the groups (OR = 0.92, 95% CI, 0.60 to 1.43). Pre-stroke low-dose aspirin was associated with improved functional outcomes and reduced mortality in patients with DMVO undergoing MT, without a significant increase in sICH. These findings suggest that low-dose aspirin may be safe and associated with more frequent excellent outcomes for this patient population. Further prospective studies are needed to validate these results and assess long-term outcomes.

Parsimonious versus extensive bleeding score: can we simplify risk stratification after percutaneous coronary intervention and reduce bleeding events by de-escalation of the antiplatelet strategy?

Background and aimsDue to the multitude of risk factors outlined in the guidelines, personalised dual antiplatelet therapy (DAPT) guidance after percutaneous coronary intervention (PCI) is complex. A simplified method was...

Trends in age and antithrombotic therapy in patients who underwent transurethral resection of bladder tumor and perioperative complications.

We investigated the subsequent trends in age and antithrombotic therapy in patients who underwent transurethral resection of bladder tumor (TURBT) and examined the rate of perioperative complications. Medical records of patients who underwent TURBT were retrospectively analyzed. We arbitrarily divided the observation years into three periods (I: 2007-2013, II: 2014-2018, and III: 2019-2023) to compare the trends in age and frequency of perioperative complications after TURBT between patients taking and those not taking antithrombotic drugs. The number of patients who underwent TURBT was 173, 224, and 224 in periods I, II, and III, respectively. The proportion of patients receiving antithrombotic drugs was similar among the three periods (34.1%, 29.9%, and 37.5% in periods I, II, and III, respectively). The percentage of patients taking antithrombotic medications who were aged ≥80 was gradually increasing. The usage of warfarin (25.4%, 13%, and 4.2% in periods I, II, and III, respectively) and aspirin (65.1%, 40.3%, and 32.3% in periods I, II, and III, respectively) was decreased, whereas direct oral anticoagulant (1.6%, 18.2%, and 35.4% in periods I, II, and III, respectively) and clopidogrel (4.8%, 15.6%, and 16.7% in periods I, II, and III, respectively) administrations was increased. The rate of hemorrhagic and cardiocirculatory complications was higher in patients receiving antithrombotic drugs than in patients not receiving them. Of the patients receiving antithrombotic therapy, two patients with a history of cardiac infarction and deep vein thrombosis passed away after TURBT due to ischemic heart disease. The age of patients receiving antithrombotic drugs has increased, and antithrombotic drug types have changed among those who underwent TURBT. Further attention to hemorrhagic and lethal cardiocirculatory complications after TURBT will be required in a super-aged society.

Essential Thrombocythemia: A Review.

Essential thrombocythemia, a clonal myeloproliferative neoplasm with excessive platelet production, is associated with an increased risk of thrombosis and bleeding. The annual incidence rate of essential thrombocythemia in the US is 1.5/100 000 persons. Patients with essential thrombocythemia have a persistent platelet count of 450 × 109/L or greater. The differential diagnosis includes myeloproliferative neoplasms (polycythemia vera, primary myelofibrosis, chronic myeloid leukemia); inflammatory conditions such as rheumatoid arthritis and systemic lupus erythematosus; infections; splenectomy; iron deficiency anemia; and solid tumors such as lung cancer. Approximately 90% of individuals with essential thrombocythemia have genetic variants that upregulate the JAK-STAT (signal transducer and activator of transcription 5) signaling pathway, including Janus kinase 2 (JAK2, 64%), calreticulin (CALR, 23%), and myeloproliferative leukemia virus oncogene (MPL, 4%). The median age at diagnosis of essential thrombocythemia is 59 years. The median overall survival exceeds 35 years in those diagnosed at 40 years or younger. Patients with essential thrombocythemia are at increased risk of arterial thrombosis (11%), venous thrombosis (7%), and hemorrhagic complications (8%). Thrombosis risk is increased among those with a history of thrombosis, age older than 60 years, a JAK2 gene variant, and cardiovascular risk factors (eg, hypertension, diabetes mellitus, hyperlipidemias, tobacco use). Use of aspirin (81-100 mg/d) is suggested for most patients with essential thrombocythemia to lower thrombosis risk. In a retrospective study of 300 affected patients with a low thrombosis risk (younger than 60 years with no prior thrombosis), those not taking aspirin (100 mg/d) had a risk of arterial thrombosis of 9.4/1000 patient-years and a venous thrombosis risk of 8.2/1000 patient years; cardiovascular risk factors were associated with a higher risk of arterial thrombi (incidence rate ratio, 2.5 [95% CI, 1.02-6.1]), and a JAK2 gene variant was associated with increased risk of venous thrombosis (incidence rate ratio, 4.0 [95% CI, 1.2-12.9]). In a randomized trial of 114 patients at higher risk for thrombosis (age older than 60 years or a prior thrombotic event), cytoreduction with hydroxyurea significantly lowered the risk of arterial or venous thrombotic events compared with no cytoreductive therapy (3.6% vs 24%; P < .01). At a median of 8.5 years from diagnosis, approximately 10% of patients with essential thrombocythemia develop myelofibrosis and about 3% develop acute myeloid leukemia. Essential thrombocythemia is a rare clonal myeloproliferative neoplasm associated with an increased risk of venous and arterial thrombosis, hemorrhage, myelofibrosis, and acute myeloid leukemia. Based on individual risk factors for thrombosis, persons with essential thrombocythemia may be treated with low-dose aspirin, either alone or in combination with a cytoreductive drug such as hydroxyurea.

Comparative Analysis of Hemorrhagic Complications in Deep Brain Stimulation: Microelectrode Recording versus Macrostimulation-Does the Technique Matter?

Hemorrhage is a dangerous complication of deep brain stimulation (DBS) surgery, but a comprehensive explanation of the associated risk factors remains inconclusive, particularly application of microelectrode recording (MER) compared with macrostimulation (non-MER)-based DBS procedures. We conducted a comparative analysis of MER and macrostimulation techniques, evaluating the impact of brain penetrations by microelectrode guiding cannulas on the occurrence of intracranial hemorrhagic events. This retrospective study included all DBS procedures (MER-based and non-MER-based) performed at a single medical center from November 2008 to June 2023. Patients underwent comprehensive preoperative and postoperative evaluations, including postoperative computed tomography to assess lead placement and intracranial bleeding, categorized as symptomatic or asymptomatic. Statistical analyses were conducted to ascertain the correlation between different surgical techniques and the risk of hemorrhagic complications. In a cohort of 618 patients, 1096 electrodes were implanted during 672 consecutive DBS procedures. There were 21 asymptomatic and 6 symptomatic intracranial hemorrhages (ICHs), including 1 death. The bleeding rate was 4.37% per patient and 2.92% per electrode. Patients who developed hematomas were more prevalent in the MER group (25 cases) compared with the non-MER group (2 cases). The MER group had a higher mean number of brain penetrations by guiding cannulas. DBS procedures are generally safe, with only 0.97% resulting in long-term or permanent deficits. All symptomatic ICH occurred in MER-based procedures, whereas macrostimulation was associated with only 2 asymptomatic ICH cases. The higher number of brain penetrations in MER correlates with higher bleeding rates.

Crimean–Congo Hemorrhagic Fever Mimicking HELLP Syndrome in a Pregnant Woman and Her Infant in Kosovo: A Case Report

Crimean–Congo hemorrhagic fever (CCHF) is fatal in 10 to 40% of cases. It is caused by CCHF virus (CCHFV). Symptoms include fever, headache, myalgia, and often hemorrhage and other complications. This report shows that CCHF may resemble HELLP syndrome (hemolysis, elevated liver enzymes, low platelets). We report CCHF in a pregnant mother with fever and suspected HELLP syndrome, who survived, and her infant (week 36), who died six days after C-section. The high CCHF viral load and bacterial sepsis may have jointly contributed to the death of the infant. CCHF should be considered as a differential diagnosis of HELLP syndrome in regions where this viral disease is endemic.

Clinical cases of the use of ESPB as a component of combined anesthesia in patients with liver resection operations

This scientific work is devoted to the topical and applied issue of modern anesthesiology – intensive care – rational anesthesia of laparoscopic liver resections. The transformation of surgical access from «open» to minimally invasive – laparoscopic and robot–assisted – encourages anesthesiologists to search for new methods of prolonged postoperative analgesia. The tendency of modern anesthesiology to limit the use of opioids and the popularization of ultrasound technologies expand the scope of application of myofascial blockades in various fields of surgery. The techniques are safe and effective and can be implemented in various groups of patients, in particular in those who has contraindications to neuroaxial block. Currently, the most commonly used method of anesthetic provision is combined anesthesia –general anesthesia and epidural analgesia. It should be remembered about the features of surgical interventions on the liver and the associated risk of developing massive blood loss syndrome, which increases the frequency of post-operative, primarily hemorrhagic complications, after the use of neuroaxial techniques of prolonged analgesia. The sympatholytic effect of local anesthetics with prolonged epidural infusion is well known, in some cases provoking hemodynamic instability, and, as a result, the need for monitoring the patient in the intensive care unit, as well as increasing the length of hospital stay in general. This circumstance contradicts the trend of modern surgery towards rapid and accelerated recovery after surgery. The above together is economically unprofitable and does not meet the requirements of modern protocols. An in-depth analysis of clinical practice led the authors to the idea of using myofascial blocks (in particular, erector spinae plane block), which have positive qualities of neuroaxial techniques, but are characterized by a better safety profile.

Systematic Ultrasound Screening for Lower Extremity Deep Vein Thrombosis in ICU Patients with Severe COVID-19: A Randomized Clinical Trial.

Venous thromboembolism (VTE), whether pulmonary embolism (PE) or deep vein thrombosis (DVT), is common in patients with COVID-19. Recommendations on systematic screening in the intensive care unit (ICU) are lacking. Is there any clinical benefit of systematic screening for DVT in critically ill patients with severe COVID-19? Single-center randomized clinical trial (RCT) of COVID-19 cases admitted to the ICU. Patients were randomized into two groups: a study group that underwent ultrasound (US) screening for DVT Mondays and Thursdays, and a control group that was treated according to the unit protocol. The primary outcome was the presence of DVT. Secondary outcomes were ICU total stay, death within 21-day follow-up and bleeding complications (minor or major). A composite outcome of poor prognosis variables was analyzed. We tested a superiority hypothesis with a confidence level of 95% and an equivalence limit of 20%. 163 patients (84 screening group, 79 control group) were enrolled between April and July 2021. There were 90 men (55.2%) with a mean ± SD age of 49.8 ± 13.58 years. In screening group 16.7% developed DVT versus 3.8% in control group (p = .007), and 3.6% versus 5.1% developed PE, respectively (p = 0.7). Poor outcome variables were male sex, age, COVID-19 vaccination status, Fibrinogen, Urea, Creatinine and Interleukin 6 (IL6) levels; Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scales. The superiority comparison, with a power of 95%, showed no statistically significant differences for a composite endpoint (p = .123). After adjusting by group, the OR for poor outcome is 1.966 (0.761-5.081) p = 0.163. Among these patients, a strategy of systematic US screening for DVT was not associated with any significant improvements to clinical outcomes compared with usual care. Clinicaltrials.org registration number: NCT05028244.

Alteplase Purge Solution for Impella 5.5 Ventricular Assist Device Purge System Occlusion: Case Report and Review of the Literature.

The use of an alteplase (Activase) purge solution to address Impella ventricular assist device "thrombosis" or "purge system occlusion" has been mainly documented with earlier generation Impella devices (CP, 2.5, 5.0). Here, we report the use of an alteplase purge solution to manage Impella 5.5 purge system occlusion in a 31-year-old male admitted to the cardiac care unit in cardiogenic shock and listed for a heart transplant. Throughout the purge system occlusion, the patient demonstrated hemodynamic stability and overall pump flow and cardiac output were preserved. Initially, there was a lack of response in purge flow and pressure observed at the lower concentration of alteplase purge solution (0.04 mg/ml), yet after using the alteplase 4 mg/50 ml purge (0.08 mg/ml) solution concentration, a response was seen. No bleeding or hemodynamic complications were observed. In addition, a suggested management workflow and review of the case reports and case series published to date regarding Impella purge system occlusion is included in this article.

Effectiveness and Safety of Ticagrelor Monotherapy After Short-Duration Dual Antiplatelet Therapy in PCI Patients: A Systematic Review and Meta-Analysis.

Dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 inhibitor, is the standard treatment for patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES). However, the optimal duration of DAPT remains debated due to the need to balance ischemic event reduction with bleeding risks. This study evaluates the efficacy and safety of ticagrelor monotherapy after short-duration DAPT (1-3 months) compared to extended DAPT, focusing on major bleeding and cardiovascular outcomes. A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Randomized controlled trials (RCTs) comparing ticagrelor monotherapy after short-duration DAPT to extended DAPT were identified from PubMed, Embase, and the Cochrane Library. Data on major bleeding, major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction, stroke, stent thrombosis, and mortality were analyzed, and risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model. Five RCTs involving 32,393 patients were included. Ticagrelor monotherapy significantly reduced MACCE (RR: 0.88; 95% CI: 0.77-0.99; p=0.04) and major bleeding (RR: 0.53; 95% CI: 0.37-0.77; p=0.0008) compared to extended DAPT. It also significantly reduced all-cause mortality (RR: 0.82; 95% CI: 0.67-0.99; p=0.04) and cardiovascular death (RR: 0.68; 95% CI: 0.49-0.94; p=0.02). The incidence of myocardial infarction, stent thrombosis, and stroke were similar between the groups. Net adverse clinical events (NACE) were 27% lower with ticagrelor monotherapy (RR: 0.73; 95% CI: 0.63-0.85; p<0.0001). In conclusion, ticagrelor monotherapy after short-duration DAPT reduces major bleeding complications without compromising cardiovascular protection. This approach offers a promising strategy to optimize outcomes for PCI patients, particularly those at high bleeding risk. Further studies are needed to refine the optimal DAPT duration in various patient populations, especially those with higher ischemic risk.

Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fifth edition)

Hemorrhagic complications associated with regional anesthesia are extremely rare. The fifth edition of the American Society of Regional Anesthesia and Pain Medicine’s Evidence-Based Guidelines on regional anesthesia in the patient...

Safety and Outcomes of Percutaneous Dilatational Tracheostomy in Patients with Hematologic Malignancies: A Retrospective Cohort Study.

Background/Objectives: Patients with hematologic malignancy (HM) often experience high rates of thrombocytopenia, thrombocytopathy, anemia, leukopenia, and coagulopathy, which can significantly increase the risk of procedural and postoperative complications. This study aimed to evaluate the safety and outcomes of percutaneous dilatational tracheostomy (PDT) in critically ill patients with HM. Methods: This retrospective cohort study included patients with HM who underwent PDT between 2012 and 2023 at a tertiary academic center. The primary outcome was early (7-day) bleeding complications rate. Secondary outcomes included PDT-related mortality, and mortality at 1 week, 30 days, and 1 year. Analyses were performed using a propensity-matched cohort to ensure balanced comparisons between groups. Results: Of the 1627 patients included in the analysis, 65 (4%) had HM. Patients with HM had a significantly higher Charlson comorbidity index and exhibited significantly higher rates of thrombocytopenia (platelet count < 100,000/mcL) compared to those without HM (8.0 [IQR 5.0-11.3] vs. 5.0 [IQR 2.0-7.0], p < 0.001; and 49.2% vs. 5.0%, p < 0.001, respectively). After propensity score matching, the one-week mortality rate was significantly higher in the HM group (23.4% vs. 4.3%, p = 0.007). However, the rates of intraoperative and bleeding complications as well as one-year mortality rates were similar between the groups. Conclusions: PDT can be safely performed in critically ill patients with HM. However, these patients exhibit high early mortality rates following the procedure.

Venoarterial Membrane Oxygenation in Cardiogenic Shock Complicated from an Acute Myocardial Infarction: An Overview and Comprehensive Meta-Analysis.

Background: Cardiogenic shock remains a significant cause of mortality in patients with acute coronary syndrome, despite early interventions, such as coronary revascularization. Mechanical circulatory support devices, particularly venoarterial extracorporeal membrane oxygenation (VA-ECMO), are increasingly being utilized to address this issue. Limited randomized controlled trials (RCTs) exist to evaluate the efficacy of VA-ECMO in cardiogenic shock related to acute coronary syndrome. Methods: A meta-analysis was conducted to assess the effectiveness of VA-ECMO in adult patients with infarct-related cardiogenic shock. Trials were identified through database searches and selected based on specific inclusion criteria. The primary outcome was 30-day all-cause mortality, with secondary outcomes including bleeding and vascular complications. Results: A total of 24 studies met the inclusion criteria and were included in the meta-analysis, involving 4706 patients. The median age of the patients was 61.8 ± 4.1 years, with 76% of them being males. The analysis revealed that 30-day mortality rates for patients with cardiogenic shock receiving ECMO were still high, with a mortality of 63%. Vascular complications were identified as factors associated with a worse prognosis. Conclusions: The meta-analysis highlights the ongoing challenge of high mortality rates in cardiogenic shock patients despite the use of VA-ECMO. While VA-ECMO shows promise in providing circulatory support, further research is needed to explore ways to improve outcomes and reduce complications associated with the use of these devices. The complexity of patient management in cardiogenic shock cases underscores the need for a multidisciplinary approach to optimize treatment strategies and enhance patient outcomes.