High Risk Of Bleeding Research Articles

Recent Advances in Diagnosis and Management of Cesarean Scar Pregnancy.

Cesarean scar pregnancy (CSP) is among the most severe iatrogenic complications of cesarean delivery (CD) and is associated with a high risk of severe hemorrhage, uterine rupture, and progression towards placenta accreta spectrum disorders. Prenatal diagnosis of CSP has been recently standardized through a modified Delphi consensus, which also allows risk stratification according of this anomaly. However, several issues on the management of CSP are still under debate. The aim of the present review is to provide an up-to-date on the diagnosis and management of CSP.

Attitude and practice of dentists in patients taking oral antiplatelet and anticoagulant medications

PurposeIn everyday practice, dentists are confronted with the dilemma of patients on antiplatelet and anticoagulant agents who require dental procedures.The present survey aimed to exhibit Turkish dentists’ awareness and attitude towards patients using blood thinners prior to dental procedures and point out the significance of this issue.MethodsAn electronic survey was administered to dental practitioners. Demographics, career details, answerbacks to medical consultation and agents consisting of 20-questions investigating approaches to patients using antiplatelet and anticoagulant agents were recorded.Data were collected in the online platform and analyzed.ResultsA total of 500 dentists answered the survey, of which 48.2% were female and 51.8% were male. %57.8 of all respondents inaccurately marked warfarin as an antiplatelet agent. In patients who underwent coronary stent implantation,24.6% of dentists unfortunately stated that they always discontinue the actual medications before surgery. The majority of cardiology consultants interrupted the drug 5–7 days before the intervention in patients receiving antiplatelet therapy.16.6% of consultants made a decision based on international normalized ratio (INR) level of the patients using direct oral anticoagulant (DOAC).ConclusionAlthough dental procedures do not posses a high bleeding risk and can be safely performed without interruption of blood thinners, there is an overestimation of the risk of bleeding by the dentists.It’s understood that a considerable number of participants are not familiar with the blood thinners, coagulation tests and perioperative management.

Association Between Time From Percutaneous Coronary Intervention to Cancer Surgery and Cardiovascular and Oncological Outcomes.

Patients who undergo noncardiac surgery shortly after percutaneous coronary intervention (PCI) experience higher rates of perioperative ischemic events, but delaying surgery may affect disease staging and influence cancer recurrence. We aimed to evaluate the association between time from PCI to cancer surgery and cardiovascular and oncologic outcomes in patients with early-stage cancer. We included patients with early-stage cancer with a history of PCI who underwent cancer surgery (N=3621). The patients were divided into 2 groups based on the time between the dates of PCI and cancer surgery (<12 and ≥12 months). We also grouped patients who underwent early surgery and late surgery, defined as patients who underwent surgery ≥1 and <1 month after cancer diagnosis. Outcomes included bleeding, spontaneous myocardial infarction, repeat revascularization, cancer recurrence, and death. The time from PCI to cancer surgery <12 months group had higher bleeding (hazard ratio [HR], 1.30 [95% CI, 1.18-1.32]), spontaneous myocardial infarction (HR,1.96 [95% CI, 1.32-2.92]), cancer recurrence (HR, 1.26 [95% CI, 1.01-1.56]), and mortality (HR, 1.23 [95% CI, 1.04-1.44]) compared with the ≥12 months group. Among the time from PCI to cancer surgery <12 months group, the early-surgery group had lower cancer recurrence risk than those who underwent late surgery (HR, 0.70 [95% CI, 0.49-0.99]) without differences in bleeding and cardiac outcome. Although patients who undergo surgery within 12 months of PCI have higher risks of bleeding and cardiovascular events, delaying surgery may increase the risk of cancer recurrence. Therefore, the timing of surgery should be a personalized decision, weighing the risks of cardiovascular complications against the potential oncologic outcomes. URL: https://www.clinicaltrials.gov; Unique Identifier: NCT06357000.

Treatment of non-ST-segment elevation myocardial infarction in the elderly: the SENIOR-RITA trial.

Non-ST-segment elevation myocardial infarction is the prevalent form of infarction, especially in the elderly population. Compared with ST-segment elevation myocardial infarction, the culprit coronary artery lesion is not always traceable, and only a proportion of cases undergoing coronary angiography result in revascularization. At present, there is no evidence that a systematically invasive strategy has better outcomes, especially lower mortality, than a conservative approach. The SENIOR-RITA trial was the largest study in this regard, having randomized 1518 patients aged ≥75 years to invasive vs. conservative strategy with follow-up up to more than 4 years. Frail patients with cognitive impairment and comorbidities were not excluded. The results showed no differences between the two strategies in terms of primary endpoint (composite of cardiovascular death and infarction) or mortality, but a significant reduction in the risk of infarction and subsequent revascularization. These results confirm those of the previous meta-analysis of studies devoted to elderly patients and should be considered in terms of intervention strategy rather than revascularization efficacy. Subsequent antithrombotic therapies need to consider the frailty of these patients and their high haemorrhagic risk, with the increasing trend towards less aggressive and prolonged therapies than in the past.

Drug-coated balloons in percutaneous coronary interventions: existing evidence and emerging hopes.

Drug-coated balloons (DCB) have been developed as an alternative to drug-eluting stents (DES) as a part of the "leave nothing behind" strategy following percutaneous coronary interventions (PCI). DCBs facilitate revascularization and delivery of an antiproliferative agent directly to a coronary artery lesion, without the need for DES implantation. Subsequently, DCBs promote positive vascular remodeling and allow for a shorter duration of dual antiplatelet therapy. Since the first reports on the successful treatment of coronary in-stent restenosis (ISR) with paclitaxel-coated balloon catheters in the year 2006, the use of DCBs has been growing, driven by reports of DCB application to treat ISR, bifurcation lesions, and small vessel disease. Contemporary clinical trials evaluating DCBs in large vessel disease and chronic total occlusions might further expand the indications for this technology. Attention has also been brought to the use of DCBs in patients with diabetes mellitus and acute coronary syndrome, especially those at high bleeding risk. This review aims to discuss the existing evidence and emerging hopes associated with DCBs, including technical aspects of DCB PCI and the use of DCBs in different clinical scenarios.

Comparison of regional citrate anticoagulation and nafamostat mesylate anticoagulation during plasma exchange for children at high bleeding risk: a retrospective study

BackgroundThere is currently no established optimal anticoagulation protocol for plasma exchange (PE) in pediatric patients at a high risk of bleeding. Therefore, we aimed to evaluate the efficacy and safety of regional citrate anticoagulation (RCA) and nafamostat mesylate (NM) for PE anticoagulation in this patient group.MethodsThis retrospective study analyzed data from 66 children with high bleeding risk who underwent PE in the Pediatric Intensive Care Unit of Hunan Children’s Hospital between June 2018 and January 2023. Patients were divided into two groups: RCA-PE (n = 45) and NM-PE (n = 21), and filter performance and adverse reaction rates were compared. Statistical analysis utilized SPSS 25.0, comprising two-sample t-tests, chi-square or Fisher’s exact tests, and Mann–Whitney U tests, as appropriate. Data visualization was performed using ggplot2 in R-studio. P < 0.05 was considered statistically significant.ResultsNo statistically significant differences were found between the two groups in initial transmembrane pressure (TMP) [17.0 (14.0, 21.5) mmHg vs. 16.0 (14.0, 19.5) mmHg, P = 0.614], maximum TMP [46.0 (42.0, 49.5) mmHg vs. 43.0 (41.5, 49.5) mmHg, P = 0.689], and final TMP [40.0 (35.5, 45.0) mmHg vs. 38.0 (35.0, 42.0) mmHg, P = 0.298]. Filter grade distribution and bleeding events also showed no statistically significant difference between the groups. However, the NM-PE group had significantly lower overall adverse reaction and metabolic alkalosis rates (both P < 0.05) compared to the RCA-PE group.ConclusionsNM demonstrates similar efficacy but superior safety compared with RCA, making it a more suitable anticoagulation strategy for children with high bleeding risk. Study limitations include single-center design, selection bias, and uncertain NM dosage.

Treatment of hemorrhagic right gastro-omental artery pseudoaneurysm via ultrasound guided percutaneous thrombin injection

Visceral artery pseudoaneurysms are life-threatening conditions due to their high risk of rupture and hemorrhage. Traditional treatments include endovascular interventions such as stent grafting and embolization, or open surgery. However, ultrasound-guided percutaneous thrombin injection is rarely used as a first-line therapy. This case report presents a 66-year-old patient with an iatrogenic hemorrhagic pseudoaneurysm of the right gastro-omental artery, successfully treated with ultrasound-guided percutaneous thrombin injection. Under local anesthesia, a 5 mL bolus of thrombin was injected into the pseudoaneurysm sac, resulting in immediate thrombosis confirmed by ultrasound and Doppler imaging. The patient demonstrated stable hemodynamics and hemoglobin levels post-procedure. Follow-up imaging showed significant regression of hemorrhagic fluid and no contrast extravasation. This case highlights ultrasound-guided thrombin injection as a safe, cost-effective, and radiation-free alternative to traditional treatments for selected visceral artery pseudoaneurysms, particularly in distal branches or emergency settings.

High lymphocyte count and bleeding risk in patients with chronic lymphocytic leukemia treated with Bruton's tyrosine kinase inhibitors.

Bruton's tyrosine kinase inhibitors (BTKi) are being increasingly used to treat patients with chronic lymphocytic leukemia (CLL). Pathological bleeding is awell-known side effect of BTKi but identifying its predictors remains achallenge. This retrospective multicenter study analyzed whether baseline absolute lymphocyte count (ALC) may be associated with bleeding risk in CLL patients treated with BTKi. Time to bleeding (TTB) was the primary outcome of interest. Atotal of 108CLL patients treated with BTKi (ibrutinib, n = 86, acalabrutinib, n = 22) were included. The median age was 70years (range 41-88 years) and 48(44.4%) were female. The median follow-up time was 32months (range 1-108 months) and 17(15.7%) bleeding events occurred during this time. Receiver operating curve analysis set the optimal cut-off value of the ALC at > 77.4 × 109/L. Patients with higher ALC presented with higher total white blood cell count (p < 0.001), lower hemoglobin (p = 0.012), higher Rai stages (p = 0.037) and higher total tumor mass (p < 0.001). Univariately, patients with higher ALC had an inferior TTB when compared to those with lower ALC (hazard ratio, HR 3.27, p = 0.016); this effect persisted in the multivariate Cox regression analysis where higher ALC (HR 4.59, p = 0.032), higher Cumulative Illness Rating Scale (CIRS, HR 4.21, p = 0.040) and the use of antiplatelets/anticoagulants (HR 3.96, p = 0.046) remained independently of each other associated with an inferior TTB. This study provides an important signal regarding the higher risk of bleeding in CLL patients treated with BTKi who present with higher ALC and higher CIRS. Further studies are needed to validate our findings and to unravel the exact pathophysiological mechanisms behind this interesting observation.

Vascular liver disorders in patients with antiphospholipid syndrome: a national retrospective multicentre study.

Antiphospholipid syndrome (APS) is an acquired autoimmune prothrombotic condition. Vascular liver disorders (VLD), such as portal vein thrombosis (PVT), Budd-Chiari syndrome (BCS) and porto-sinusoidal vascular disorder (PSVD), are rare and related to an underlying hypercoagulable state in most cases. We aimed to describe the clinical and immunological features of APS patients with VLD. The study is a national, multicentre, retrospective study of APS patients followed in 4 French tertiary university centres, including 3 national referral centres for rare autoimmune diseases. Clinical, serological and liver characteristics at diagnosis of APS patients with VLD were collected. New thrombotic events and major bleeding during follow-up were analysed. Forty-one VLD were reported in 34 APS patients (59% women; mean age 35+/-15 years; 65% of primary APS) including PVT (n = 26/41, 63%), BCS (n = 12/41, 29%) and PSVD (n = 3/41, 7%). VLD was the first thrombotic event in 79% (n = 27/34) of patients. Fifteen patients (n = 15/34, 44%) had portal hypertension, including 10 (n = 10/34, 29%) with esophageal varices at the time of VLD diagnosis. All patients were treated with oral anticoagulants including VKA in all but one case. Over a median of 9.5 (5;14) years of follow-up, 62% (n = 21/34) of patients displayed a new thrombotic event and 26% (n = 9/34) suffered major bleeding. Although rare, VLD may be the presenting manifestation of APS. APS patients with VLD are at high risk of both recurrent thrombotic events and major bleeding.

Predicting placenta accreta spectrum and high postpartum hemorrhage risk using radiomics from T2-weighted MRI

BackgroundAntenatal diagnosis of placenta accreta spectrum (PAS) is of critical importance, considering that women have much better outcomes when delivery occurs at a level III or IV maternal care facility before labor initiation or bleeding, thus avoiding placental disruption. Herein, we aimed to investigate the performance of magnetic resonance imaging (MRI) in antenatal prediction of PAS and postpartum hemorrhage (PPH).MethodsThis retrospective study included 433 women with singleton pregnancies (PAS group, n = 208; non-PAS group, n = 225; PPH-positive (PPH (+)) group, n = 80; PPH-negative (PPH (-)) group, n = 353), who were randomly divided into a training set and a test set in a 7:3 ratio. Radiomic features were extracted from T2WI (T2-weighted imaging). Features strongly correlated with PAS and PPH (p < 0.05) were selected using Pearson correlation, followed by LASSO regression for dimensionality reduction. Subsequently, radiomics models were constructed for PAS and PPH risk prediction, respectively. Regression analyses were conducted using radiomics score (R-score) and clinical factors to identify independent clinical risk factors for PAS and PPH, leading to the development of corresponding clinical models. Next, clinical-radiomics models were built by combining R-score and clinical risk factors. The predictive performance of the models was evaluated using nomograms, calibration curves, and decision curves.ResultsThe clinical-radiomics models and radiomics models for predicting PAS and PPH risk both outperformed their clinical models in the training and testing sets. For PAS, the AUC (Area Under the Receiver Operating Characteristic Curve) of the clinical-radiomics model, radiomics model, and clinical model in the training set are 0.918, 0.908, and 0.755, respectively, and in the testing set, the AUCs are 0.885, 0.866, and 0.771, respectively. For PPH, the AUCs of the clinical-radiomics model, radiomics model, and clinical model in the training set are 0.918, 0.884, and 0.723, respectively, and in the testing set, the AUCs are 0.905, 0.860, and 0.688, respectively. The DeLong test p-values between the clinical-radiomics models and radiomics models for predicting PAS and PPH are both less than 0.05. Additionally, in the testing set, the clinical-radiomics models perform best in predicting PAS and PPH risk, with accuracies of 82.31% and 84.61%, respectively.ConclusionThis novel clinical-radiomics model has a robust performance in predicting PAS antepartum and predicting massive PPH in pregnancies.

Efficacy and safety of oral anticoagulants in patients with atrial fibrillation and acute myocardial infarction: a systematic review and meta-analysis.

The optimal antithrombotic therapy strategies for patients with atrial fibrillation (AF) and acute myocardial infarction (AMI) remain uncertain. We aimed to evaluate the efficacy and safety of oral anticoagulants (OAC) among patients with AF and AMI. PubMed, Embase, and Web of Science were searched from inception till 5 February 2025. The primary outcome was any stroke. Eleven studies with 83 549 patients were included. OAC therapy was associated with lower risks of any stroke (odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.60-0.77; P < .001), ischemic stroke (OR: 0.64; 95% CI: 0.57-0.73; P < .001), and all-cause mortality (OR: 0.81; 95% CI: 0.74-0.89; P < .001). Additionally, OAC therapy was associated with a higher risk of any bleeding (OR: 1.24; 95% CI: 1.06-1.46; P = .009), but not for major bleeding (OR: 1.28; 95% CI: 0.87-1.90; P = .21). OAC therapy is effective for patients with AF and AMI, but should be administered cautiously in those at high bleeding risk.

Validation of High Ischemic and Bleeding Risk Criteria of European Guidelines in Peripheral Arterial Disease.

The 2024 European Society of Cardiology (ESC) guidelines for peripheral arterial disease (PAD) propose the dedicated high ischemic risk (HIR) and high bleeding risk (HBR) criteria. The purpose of this study was to validate the ESC-HIR and HBR criteria using real-world data. From January 2019 to December 2022, this multicenter retrospective registry included 824 patients undergoing endovascular treatment for aortoiliac and femoropopliteal PAD. The ESC-HIR criteria include previous amputation, critical limb-threatening ischemia, previous revascularization, high-risk comorbidities (heart failure, diabetes, polyvascular disease), and estimated glomerular filtration rate<60mL/min/1.73m2, while the ESC-HBR criteria include dialysis or renal impairment (estimated glomerular filtration rate<15mL/min/1.73m2), acute coronary syndrome<30days, history of stroke or transient ischemic attack, and active or clinically significant bleeding. Although patients were initially divided into 4 groups according to the presence or absence of HIR and HBR, patients with HBR and no HIR were excluded caused by the small sample size (n=2). Major adverse cardiovascular and limb events and bleedings were evaluated. Of the 822 patients, 62 (7.5%), 467 (56.8%), and 293 (35.6%) were grouped in the HIR (-)/HBR (-), HIR (+)/HBR (-), and HIR (+)/HBR (+). During the median follow-up period of 726days, major adverse cardiovascular and limb events occurred in 0%, 9.5%, and 16.4% among the 3 groups (P = 0.005). The incidence of major bleeding events was 4.8%, 2.4%, and 6.8%, respectively (P = 0.009). The ESC-HIR and HBR criteria successfully stratified ischemic and bleeding risks in patients with PAD undergoing endovascular treatment.

Safety of cold snare resection techniques for removal of small colon polyps in patients with clopidogrel and aspirin: A Korean Association for the Study of Intestinal Diseases prospective, multicenter study

Safety of cold snare resection techniques for removal of small colon polyps in patients with clopidogrel and aspirin: A Korean Association for the Study of Intestinal Diseases prospective, multicenter study

Transvenous approach: a promising strategy for endovascular treatment of cribriform plate dural arteriovenous fistula

OBJECTIVE Cribriform plate dural arteriovenous fistula (DAVF) is a rare lesion associated with a high risk of bleeding. Transarterial embolization (TAE) has been widely recognized as the first-line treatment. However, limited data exist regarding the safety and efficacy of transvenous embolization (TVE). The aim of this study was to report on a cohort of patients with cribriform plate DAVFs who underwent endovascular treatment (EVT), detailing both clinical and angiographic outcomes. METHODS This single-center case series was conducted from January 2016 to June 2024, including 26 cases in which cribriform plate DAVFs were treated with EVT. A retrospective review of clinical and radiological data was performed. The safety and efficacy of TAE and TVE were compared and further analyzed by including results from the literature published over the past decade. RESULTS A total of 25 patients (mean age 60.2 ± 8.3 years; all male) in 26 cases were included in this study. The immediate postoperative total embolization rates were 53.8% (7/13) and 100% (13/13) for TAE and TVE, respectively, resulting in an overall success rate of 76.9% (20/26). TVE demonstrated a significantly higher success rate than that of TAE (p = 0.015). Three TAE cases had surgical complications, including microcatheter fracture (2/3) and thromboembolism (1/3). The TVE group experienced no symptomatic complications. Similar results were observed in the literature review. CONCLUSIONS TVE might be considered as a preferential strategy for cribriform plate DAVFs in select cases. For optimal safety, it is crucial to navigate microcatheters into the cortical vein using the wire-loop technique. Further studies are required to validate its safety and efficacy.

New targets for antithrombotic medications: seeking to decouple thrombosis from hemostasis.

New targets for antithrombotic medications: seeking to decouple thrombosis from hemostasis.

Prediction of risk of blood transfusion in patients with cirrhosis.

Blood transfusion is usually required for cirrhotic patients with bleeding which is related to high risk of mortality. Identifying cirrhotic patients at high risk of bleeding and needing blood transfusions would benefit these patients, yet this remains an unmet need. This study aims to enhance blood transfusion management for patients with cirrhosis by developing a predictive model to assess the risk of transfusion. We enrolled a cohort of 711 patients diagnosed with cirrhosis at The First Affiliated Hospital of Nanjing Medical University and divided into training set ( n = 537) and validation set ( n = 174). Each participant underwent a comprehensive clinical assessment. Data on prothrombin time (PT), platelet counts, and inflammatory markers were collected. Univariate and multivariate logistic regression analyses were performed to identify independent predictors. The nomogram was constructed. Model performance was evaluated through receiver operating characteristic curve analysis. The study successfully identified PT, platelet counts, and the mentioned inflammatory markers as significant predictors of the need for transfusion. The resulting nomogram demonstrated high predictive accuracy, with area under the curve values of 0.85 in the training set and 0.83 in the validation set. The developed nomogram for predicting the need for blood transfusion in patients with cirrhosis shows promising effectiveness for clinical application. This tool can significantly contribute to optimizing transfusion practices, potentially improving patient care and outcomes through more personalized and efficient transfusion strategies.

Caplacizumab treatment in elderly patients with iTTP: Experience from the Spanish TTP Registry.

Immune thrombotic thrombocytopenic purpura (iTTP) typically affects middle-aged individuals, although it sometimes appears in older patients. Caplacizumab is approved for the treatment of iTTP, but information on the safety and efficacy of this drug in elderly patients is not available. We aimed to analyze the management and outcomes of iTTP patients registered in the Spanish TTP Registry and receiving caplacizumab at any time during the acute episode, focusing on patients ≥60 years (n = 29) and comparing them with patients <60 years (n = 70). Severe bleeding motivated caplacizumab's initiation delay in one patient ≥60 years. Patients receiving anticoagulation or antiplatelet therapy at diagnosis were more common in older patients (10% vs. 1%; p = 0.074), as well as the occurrence of bleeding motivating caplacizumab discontinuation (17% vs. 1%, respectively; p = 0.008). Caplacizumab seemed to be efficient in the treatment of iTTP in older patients, reducing refractoriness and death to 3% and exacerbation to 10%, similar to younger patients. The higher risk of bleeding in this older population warrants the need for close monitoring during treatment and to further explore the best management of thrombotic and bleeding risk.

Long-term Antithrombotic Therapy in Patients With Chronic Coronary Syndrome: An Updated Review of Current Evidence.

Long-term Antithrombotic Therapy in Patients With Chronic Coronary Syndrome: An Updated Review of Current Evidence.

Single vs dual antiplatelet therapy after left atrial appendage closure: A propensity score matching analysis.

Single vs dual antiplatelet therapy after left atrial appendage closure: A propensity score matching analysis.

The Role of Tranexamic Acid in Postpartum Hemorrhage in the High-Risk Obstetric Patient: A Retrospective Study.

Postpartum hemorrhage (PPH) remains one of the leading causes of maternal death in the United States. There are several risk factors known to increase the risk of PPH and the use of tranexamic acid (TXA) has been widely researched in clinical situations with high bleeding risk. This retrospective observational study of the role of TXA and PPH in 418 high-risk obstetric patients was completed at a community hospital, and information on TXA administration, blood/colloid administration, and intraoperative and 24-hour estimated blood loss was evaluated for all patients who had a cesarean section within the study parameters. TXA doses ranged from .001 g to 2 g with a mean of 1.03 g (SD = 0.21). Using Games-Howell post-hoc testing, mean 24-hour EBL differed significantly among all groups except the uterotonics only group, which did not differ significantly from any other group. Twenty four-hour estimated blood loss was highest in those receiving both TXA and other uterotonic agents and lowest in those receiving neither.