Hypercoaguable State Research Articles

The Influence of Hyperthyroidism on the Coagulation and on the Risk of Thrombosis.

Introduction: Apart from the well-known fact that hyperthyroidism induces multiple prothrombotic disorders, there is no consensus in clinical practice as to the impact of hyperthyroidism on the risk of thrombosis. The aim of this study was to examine the various hemostatic and immunologic parameters in patients with hyperthyroidism. Methods: Our study consists of a total of 200 patients comprised of 64 hyperthyroid patients, 68 hypothyroid patients, and 68 euthyroid controls. Patient thyroid status was determined with standard tests. Detailed hemostatic parameters and cardiolipin antibodies of each patient were determined. Results: The values of factor VIII (FVIII), the Von Willebrand factor (vWF), fibrinogen, plasminogen activator inhibitor-1 (PAI-1), and anticardiolipin antibodies of the IgM class were significantly higher in the hyperthyroid patients than in the hypothyroid patients and euthyroid controls. The rate of thromboembolic manifestations was much higher in hyperthyroid patients (6.25%) than in hypo-thyroid patients (2.9%) and euthyroid controls (1.4%). Among hyperthyroid patients with an FVIII value of ≥1.50 U/mL, thrombosis was recorded in 8.3%, while in hyperthyroid patients with FVIII value ≤ 1.50 U/mL the occurrence of thrombosis was not recorded. The incidence of atrial fibrillation (AF) was significantly higher (8.3%) in the hyperthyroid patients compared to the hypothyroid patients (1.5%) and euthyroid controls (0%). Conclusions: High levels of FVIII, vWF, fibrinogen, PAI-1, and anticardiolipin antibodies along with other hemostatic factors contribute to the presence of a hypercoaguable state in patients with hyperthyroidism. The risk of occurrence of thrombotic complications is especially pronounced in patients with a level of FVIII exceeding 150% and positive anticardiolipin antibodies of the IgM class. Patients with AF are at particularly high risk of thrombotic complications due to a hyperthyroid prothrombotic milieu.

Estimating the Burden of Venous and Arterial Thrombotic Events in Hospitalized Adults with COVID-19; A National Multicenter Cohort Study

Background: Patients infected with Coronavirus Disease 2019 (COVID-19) have clinical and laboratory features consistent with a hypercoaguable state, particularly in more severely ill patients that require hospitalization. However, estimates of thrombotic complications in this high risk population vary widely. A geographic representative cohort to explore the rates of thrombotic events in patients hospitalized with COVID-19 in the United States would be useful to better understand the burden of thrombosis in this population. We aimed to assess the rates of venous and arterial thrombosis events during hospitalization in patients with COVID-19 in a national multicenter cohort study. Methods: We conducted a retrospective cohort study of hospitalized patients diagnosed with COVID-19 from January 1 2020 to January 2023. IRB approval was obtained at each site. Inclusion criteria included adults (> 21 years), hospitalized for >1 day and laboratory confirmation of polymerase chain reaction testing of severe acute respiratory syndrome coronavirus 2. Data were extracted by participating centers in a pre-specified instrument from the electronic medical record at each institution and pooled prior to analysis. Data sources included manual extraction by study investigators in 7 sites and electronic extraction based on billing codes at one site (Cleveland Clinic). Primary outcome was venous thrombotic events, including deep vein thrombosis (DVT), pulmonary embolism (PE). Unusual sites including splanchnic vein thrombosis and cerebral venous thrombosis were included if objectively demonstrated on imaging. Arterial thrombotic events including ischemic stroke, acute coronary syndrome were included as secondary outcomes. Data are presented as proportions, with binomial 95% confidence intervals (CI). Results: We included 33,769 patients from eight medical centers across the United States. Participating hospitals included all four census regions from the North East (Beth Israel Deaconess Medical Center, MA (n=1021) Rochester Regional Hospital, NY (n=99)), South (John Hopkins Medical Institute, ML (n=334); Baycare Health System, FL (n=3734), MidWest (Cleveland Clinic Foundation, OH (n=25467); Henry Ford Health System, MI (973); University of Illinois, IL (1192)) and West (University of California, CA (n=613)). (Figure) Of the total 33,433 hospitalized patients with COVID-19 included, 1684 patients developed a venous thrombotic event during the index hospitalization (5.0%, 95% CI 4.8-5.2) and 261 developed an arterial thrombotic event (0.8%, 95% CI, 95% CI 0.7-0.9). Rates of venous events by individual sites ranged from 2.6-8% and arterial events from 0.3-6.6%. Conclusion: In this national multicenter cohort study that included academic and community hospitals from all four US census regions, we estimated the rates of VTE were over five times more frequent than arterial events in hospitalized patients with COVID-19. Accurate estimates of thrombotic rates and trends can help plan targeted interventions related to strategies around thromboprophylaxis interventions and resource allocation for future surges of COVID-19 cases.

Paget-Schroetter Syndrome: A Case Report of effort induced upper extremity venous thrombosis

Effort induced thrombosis of the axillary-subclavian vein, also referred as Paget-Schroetter syndrome, is a relatively uncommon type of deep vein thrombosis of the upper extremity. Although rare, understanding its clinical presentation and etiology is essential for timely diagnosis and formatting correct treatment protocols. Most upper extremity deep vein thrombosis are secondary to either underlying pathology including cancer, chronic indwelling catheters, and hypercoaguable states making their clinical diagnosis relatively straight forward. On the contrary, effort induced deep vein thrombosis most commonly occur in young otherwise healthy people. Early detection and treatment of this type of thrombosis are essential in preventing late-term complications including post-thrombotic syndrome, and pulmonary embolus. There is no current consensus in treatment of effort induced upper extremity thrombosis with literature supporting conservative versus surgical treatment depending on patient presentation and physician preference.

Covid-19 With Cerebrovascular Manifestations: Review of Literature and Case Series

Background: In year 2020, we are fighting with global threat of corona virus pandemic. It is more hazardous with its heterogeneous presentation involving all systems in body. Objective: As corona virus having properties to produce cerebrovascular diseases via causing hypercoaguable state and possible endothelial damage, it is necessary to look this facet of its virulence. Here, we are presenting review of literature and case series of three patients having covid stroke, two of which having ischemic stroke and one of them is having hemorrhagic stroke. Methods and Material: This study has been carried out at SVP hospital Ahmedabad which is designated covid care hospital in western India from March to august. With no proper etiopathogenesis established between covid-19 and stroke, this data is useful as obtained from dedicated covid hospital in western India with drainage area of approximately 6,00,00,000 population. Result: Mortality is higher in patients with cerebrovascular manifestation with hypercoagulability and thrombotic complications. Conclusion: Neurological examination must be given proper importance in apparently well covid-19 positive patients to reveal minute neurological clues. A centralized database needed to be established at national level. Once covid-19 can be established as direct causative agent, a term “covid stroke” must be given proper importance and guideline can be formed for treatment.

ADAMTS13 levels in sickle cell anaemia

Background Sickle cell anaemia (SCA) is a hypercoaguable state characterized by a significant alternation in haemostatic parameters which may predispose to increased risk of vas-occlusive crisis (VOC). The role of ADAMTS13 in the pathogenesis of VOC has not been fully investigated in our environment. Objective The objective of this study is to evaluate the level of ADAMTS13 in SCD subject in Calabar and to determine their role in the pathogenesis of vaso-occlusive crisis. Materials and methods This is a comparative study carried out at the University of Calabar Teaching Hospital (UCTH), Calabar. In all, 60 SCA patients were evaluated in VOC and steady states well are 50 apparently healthy controls. ADAMTS13 Ag was evaluated using Assaypro enzyme-linked immunosorbent assay kits with LOT Nos 04222167 R. Data were analyzed with IBM SPSS Chicago software version 21. The study was approved by the UCTH Institution Ethical Review Board. Results The mean ages of the SCA subjects and controls were 23.5 + 7.2 yrs and 26.5 + 5.6 years respectively (P=0.706). There were 23 (38.3%) males in the SCA group and 21 (42.0%) females in the controls. There was no significant difference in their sex distribution (P=0.063). The mean (SD) of ADAMTS13 in VOC, steady-state, and controls were 0.61 + 0.10 ug/l, 0.44 + 0.06 ug/l, and 0.62 + 0.10 ug/l respectively. ADAMTS13 levels did not differ significantly across the groups (P=0.270). Conclusion ADAMTS13 level is not elevated both in steady-state and vaso-occlusive crisis

Evaluation of hemostasis in hyperthyroid cats.

BackgroundHyperthyroid cats might have a predisposition to arterial thrombus formation. The mechanism for thrombogenesis currently is unknown but could be associated with systemic hypercoagulability as seen in hyperthyroid humans.ObjectiveOur purpose was to evaluate markers of hemostasis in hyperthyroid cats compared to healthy cats, and in hyperthyroid cats before and after radioactive iodine treatment (RIT).AnimalsTwenty‐five cats with hyperthyroidism and 13 healthy euthyroid cats >8 years of age.MethodsProthrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen concentration, antithrombin (AT), D‐dimers, thrombin‐antithrombin complexes (TAT), von Willebrand Factor antigen (vWF : Ag), and activity of factors VIII and IX were measured. An echocardiogram was performed in all cats. Hemostatic markers and echocardiogram were evaluated again 6 to 9 months after successful RIT in 7 cats.ResultsHyperthyroid cats had higher fibrinogen concentration (P < .0001), AT activity (P < .0001), and vWF : Ag concentration (P = .01) than healthy control cats with all results decreasing significantly post‐RIT. Hyperthyroid cats were not more likely to be in a hypercoaguable state than euthyroid cats (P = .08). Serum T4 concentration was not a predictor of a hypercoagulable state (P = .53).Conclusions and Clinical ImportanceHyperthyroid cats have evidence of altered hemostasis that does not appear to be solely attributable to cardiac abnormalities, but no evidence of a hypercoagulable state. Findings suggest altered hemostasis resolves after RIT. Hyperthyroid cats could have endothelial dysfunction as indicated by increased vWF : Ag which could potentiate thrombogenesis.

Pulmonary infarcts in COVID-19

SARS-CoV-2 binds to the angiotensin-converting enzyme 2 (ACE2) receptors found on vascular endothelial cells among others.1 Goshua et al. reported that von Willebrand factor is released by activated vascular endothelial cells and modulates platelet adhesiveness and aggregation; it was most elevated in sickest COVID-19 patients.2 Thus, the endothelial cell infection leads to a hypercoaguable state providing a rationale for the extent of microthrombi seen in those who succumbed to the disease.

Study of serum level and immunohistochemical expression of von Willebrand factor in psoriasis

ABSTRACT Von Willebrand factor (vWF) is angiogenic, hypercoagulable, and inflammatory marker that increases inflammation and vasculitis and reflects endothelial cells dysfunction. vWF could play a role in psoriasis pathogenesis and prognosis. To assess the serum and immunohistochemical expression of vWF in psoriasis to evaluate its possible role in disease pathogenesis and prognosis. This case-control study included 30 cases of psoriasis vulgaris with different degrees of severity and 30 age- and sex-matched healthy controls. Serum level of vWF was measured by ELISA. Immunohistochemical staining of skin biopsies for von Willebrand factor (vVF) antibody was done. Significantly higher vWF serum level in cases (24.3 ± 14.0) vs (15.7 ± 6.85) for controls (p = .002) and significantly higher epidermal expression intensity in patients than in controls (P value = .001). There was also significant difference between cases and control regarding the dermal expression of vWF in inflammatory cells, adenexa, and endothelial cell (P value = .001, 0.065, 0.004, respectively,). Von Willebrand factor could be used as an indicator of the hypercoaguable state which may develop in patients with psoriasis and may serve as a new therapeutic target in psoriasis treatment protocols. Patients with psoriasis especially those with high PASI score are more prone to develop vascular complication. Serum vWF could be used as a better marker for psoriasis severity than PASI which is considered the gold-standard noninvasive assessment but it only measures skin involvement, while psoriasis is considered a systemic disease.

Clot Formation Under Physiological Flow Conditions Is Altered in Sickle Cell Disease As Measured By a Multiparameter Microfluidic System

Background: While the hallmark of sickle cell disease (SCD) is vaso-occlusion, it is now clear that hypercoagulation plays a prominent role in the pathophysiology of SCD (Sparkenbaugh 2017). Consistent with this prothrombotic state, SCD patients remain at increased risk for thromboembolic events (Naik 2014) such as pulmonary embolism and deep vein thrombosis. In addition, sickle red blood cells (RBC) are known to biochemically contribute to the hypercoaguable state through hemolysis or enhanced PS exposure (Whelihan 2016, Litvinov 2017). However, no studies have examined the biophysical contribution of RBCs to clot formation in SCD, especially under physiologic flow conditions. As both the increased stiffness and adhesion of the sickle RBC (Kasschau 2016) biophysically amplify the frequency and duration of interactions with the developing clot, we hypothesize that enhanced RBC incorporation occurs in sickle cell clots under physiologic flow conditions. Furthermore, as the altered shape and stiffness of sickle RBCs decreases the packing density in clots (Tutwiler 2015, Strauss 2015), we also hypothesize that the application of fluidic forces to the clots likely causes instability potentially leading to thromboemboli. This highlights the need for an assay that studies both clot formation and stability under flow conditions.Innovation: While studying these events in vivo remains the most physiologically relevant approach, the inability to control the cellular and physical parameters renders mechanistic studies to be extremely challenging. Moreover, while in vitro microfluidics offer the unique ability to precisely control parameters known to affect clot formation, including shear stress, hematocrit, platelet count, and oxygen tension, these devices typically cannot be used for extended time studies due to confounding systemic clotting throughout the fluidic. To that end, we developed a novel multi-parameter microfluidic that precisely controls the spatial location of clot initiation and formation for extended (>30 mins) in vitro studies of developing clots using recalcified citrated whole blood (Figure 1a). Our easy-to-use system combines on-chip calcification (Lehmann 2015) to reduce systemic clotting, simple assembly methods (Myers 2017), and protein micropatterning using collagen and tissue factor. Brightfield and fluorescent microscopy was used to examine the flow of blood over this patch to observe the clot formation process, structure, and stability.Results: The device performed as designed and maintained perfusion for at least 45 minutes with each trial for healthy AA donors (Figure 1b). Our preliminary images qualitatively show that clots from SS patients on hydroxyurea are larger than AA clots (Figure 1b-c). Quantitative measurements of the clot areas indicate that the clot size is significantly higher in SCD blood (n=3 patients, Mann-Whitney, p= 0.007) than in blood from healthy AA subjects (n=21) (Figure 1d). This suggests that even in the modern age of hydroxyurea therapy, patients remain in a prothrombotic state. Furthermore, after SCD whole blood clots were formed in our microfluidic system, force applied via continuous exposure to high shear stress of ~3000 dynes/cm2 in the microfluidic created clot fragments composed primarily of RBCs. The creation of these fragments suggests decreased clot stability and has implications for micro-thromboemboli (Figure 1e). These results support our hypothesis that enhanced RBC incorporation in SCD alters the structure and stability of whole blood clots. Ongoing studies are focused on defining the compositional variability and susceptibility to embolism.Conclusion and Relevance: Ongoing studies involve integrating and varying shear stress, hematocrit, platelet count, and oxygen tension to determine how these multiple parameters interact to affect the incorporation of sickle RBCs in thrombi, as our novel microfluidic enables real time visualization of clot formation and clot stability under physiologic flow conditions (Figure 2). Our device allows us to examine the stability of these clots under shear stress and the propensity for emboli formation. Collectively, these studies will lead to a better understanding of the prothrombotic state of SCD and how the sickle RBCs interacts with platelets and the coagulation cascade. [Display omitted] DisclosuresLam:Sanguina, LLC: Equity Ownership.

763 Hemostasis changes among COVID-19 gravidas during SARS-CoV-2 pandemic on rotational thromboelastography

The novel coronavirus infection, COVID-19, is characterized by an exaggerated inflammatory response that is reported to manifest as coagulopathy in up to 50% of severe cases. Despite a majority of patients receiving low-molecular weight heparin (LMWH), data suggests a high incidence of venous thromboembolic events (VTEs). Pregnancy is a hypercoaguable state that predisposes gravidas to VTEs. Rotational thromboelastography (ROTEM) is a point-of-care viscoelastic device that uses whole blood sample to define coagulation and fibrinolysis in a particular patient. It is shown to be useful in evaluating clot kinetics in trauma and acutely bleeding patients. This study aims to describe the hypercoaguable effect of COVID-19 in gravidas using ROTEM. A prospective observational study was employed to collect ROTEM parameters (EXTEM, INTEM, FIBTEM) between May and September 2020 from gravidas on admission for labor or scheduled delivery at Yale-New Haven Hospital. ROTEM was run for panels EXTEM (extrinsic hemostasis), INTEM (intrinsic hemostasis), FIBTEM (fibrin assay). One way ANOVA was performed to assess mean differences in ROTEM parameters between COVID-positive and COVID-negative term gravidas at the time of hospital admission. Thirty-nine samples were collected from 19 COVID-positive women and 20 COVID-negative women as the control. Of all standard measurements, the significant findings were: A10 (clot firmness at 10 minutes) [F(2)) = 18.3, p = 0.0001],Mean COVID - = 69.8; Mean COVID + = 61.6;ALPHA (angle between baseline and clotting curve) [F (2)= 4.13, p = 0.05], Mean COVID - = 77.3, Mean COVID + = 74.7;CFT (clot formation time) [F(2) = 5.6, p = 0.02],Mean COVID- = 63.7,Mean COVID + = 79.3 These observations support the that COVID-positive gravidas are more hypercoaguable than their COVID-negative matches.Though statistical significance is demonstrated in this early data, a more robust exploration of this population is needed to determine whether clinical significance exists as well in this at-risk group.

Frequency and Predictors of Early Seizures Following First Acute Stroke: Data from a University Hospital in South India.

Stroke is a common neurological condition, and post-stroke seizures are known to occur. Early seizures may suggest the severity of insult and may have an effect on the outcome. There are conflicting results on the frequency of early seizures, and studies from India are scarce. To study the frequency and predictors of early seizures following the first acute stroke, both arterial and venous stroke, as well as to assess their effect on clinical outcome. This is a hospital-based, prospective, observational study conducted among 279 eligible consecutive patients admitted in the Neurology department with first acute stroke, including venous stroke. The demographic data, clinical history, risk factors, examination, and all other relevant investigations are done. Early seizures occurring within 7 days of the acute stroke are identified and correlated to various risk factors. Out of the 279 patients enrolled in the study, ischemic stroke (IS) (62.4%) was the most common stroke subtype, followed by hemorrhagic stroke (HS) (20.4%), cerebral sinus venous thrombosis (CSVT) (15.8%), and IS with hemorrhagic transformation (ISH) (1.8%). Thirty-three patients (11.8%) had early seizures, among them CSVT 18 (40.9%) had the highest frequency followed by ISH 1 (20%), HS 5 (8.7%), and IS 9 (5.2%). The frequency of early onset post-stroke seizures is 11.8%, with most of them occurring within 24 hours. Venous stroke, large lesion, cortical location, supratentorial location, hypercoaguable states, and hyperhomocysteinemia are independent predictors. Duration of hospital stay is increased in patients with early seizures, however, they did not influence the in-hospital mortality.

Stroke In Young, Hyperhomocysteine and Associated With COVID-19 Illness- A Case Report

As COVID-19 patients are at high risk of thrombotic complications this makes physician aware of close monitoring of both neurological status and cardiovascular status. Along with involvement of respiratory system, pathological process carries both inflammation and hyper coagulopathy both simultaneously. Homocystein as high risk predictor of stroke in young which is unmasked due to hypercoaguable state of COVID-19.

Cancer and thrombosis: new insights to an old problem.

Venous thromboembolism (VTE) is a common complication in patients with cancer and portends a poor prognosis. Our understanding of the underlying pathophysiology of VTE in cancer has advanced since Trousseau first described hypercoagulability in patients with malignancy and Virchow described his famous triad of thrombosis formation. Malignancy itself induces a thrombophilic state by increasing the risk of venous stasis, endothelial injury and an imbalance of pro and anti-thrombotic factors leading to a hypercoaguable state. Additional insults to this thrombotic balance are introduced by patient-specific, treatment related and tumor-specific factors. The importance of understanding the factors associated with increased thrombosis in cancer is paramount in order to adequately identify patients who will benefit from thromboprophylaxis.

Clinico-Pathogenesis of COVID-19 in children

The recent pandemic by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) causing Coronavirus disease-2019 (COVID-19) affects mainly adults and to a lesser extent children. The major route of spread is via droplets where the virus is released into the air in the form of droplets by an infected individual during coughing and sneezing. The virus primarily infects the respiratory tract epithelium. Its spike protein interacts via ACE-2 receptor and facilitates the entry of the virus into the cells by membrane fusion. The activated Cytotoxic T cells and other cells cause an exaggerated inflammatory response releasing huge amounts of pro-inflammatory cytokines like interleukins and interferon. Due to this surge in the cytokine levels leading to a storm like state, there is significant endothelial injury causing hyper-coaguable state and disseminated intravascular coagulation. The common presentation in children include involvement of respiratory system leading to pneumonia, severe pneumonia, acute respiratory distress syndrome and rarely multiorgan involvement.

Spinal epidural hematoma in a patient on chronic anticoagulation therapy performing self-neck manipulation: a case report

BackgroundSpinal epidural hematoma is a rare condition usually secondary to trauma and coagulopathy. To the best of our knowledge, we present the first case of a patient with an iatrogenic hypercoaguable state performing self-neck manipulation, which resulted in a spinal epidural hematoma and subsequent quadriparesis.Case presentationA 63-year-old man presented to the emergency department with worsening interscapular pain radiating to his neck 1 day after performing self-manipulation of his cervical spine. He was found to be coagulopathic upon admission, secondary to chronic warfarin therapy for the management of atrial fibrillation. Approximately 48 h after the manipulation, the patient became acutely quadriparetic and hypotensive. Urgent magnetic resonance imaging revealed a multilevel spinal epidural hematoma from the lower cervical to thoracic spine.ConclusionsPartial C7, complete T1 and T2, and partial T3 bilateral laminectomy was performed for evacuation of the spinal epidural hematoma. Following a 2-week course of acute inpatient rehabilitation, the patient returned to his baseline functional status. This case highlights the risks of self-manipulation of the neck and potentially other activities that significantly stretch or apply torque to the cervical spine. It also presents a clinical scenario in which practitioners of spinal manipulation therapy should be aware of patients undergoing anticoagulation therapy.

Asian Study of Cerebral Venous Thrombosis

Background/Objective: Most of the studies and registries related to cerebral venous thrombosis (CVT) are reported from European countries and the United States. The objective of the present study is to identify risk factors, presentation, and outcome of CVT in Asian patients. Methods: Asian CVT registry is a prospective multinational observational study that included patients (aged > 16 years) with symptomatic CVT. Results: Eight hundred and twelve patients (59% women) from 20 centers in 9 Asian countries were included. Mean age of the patients was 31 years. Motor weakness in limbs was present in 325 (40%) patients. One hundred and eighty (22.1%) patients had a normal Glasgow coma scale (GCS) at presentation, and another 529 patients (65%) had GCS between 11 and 14. The rest (103; 13%) had a GCS of less than 10 at presentation. Permanent risk factors were present in 264 (33%) patients, transient in 342 (42%) patients, both in 43 (5%) patients and no risk factors were found in 163 (20%) patients. Anemia was present in 51%, use of oral contraceptive pills (OCP) was present in 12% women and a hypercoaguable state was present in more than 40% of those tested. One hundred and forty-three cases (18%) were in women who were either pregnant (18; 2%) or in the puerperium (up to 6 weeks postpartum; N = 125; 15%). A total of 86 (10.5%) patients were diagnosed with infection in any part of the body. The most common MRI finding was local brain edema or ischemia (53.3%) followed by hemorrhage (26.7%). Twenty-seven patients (3.3%) died during hospital stay. The mRS score at discharge was available for 661 (81%) patients. Of these, 577 (87.3%) had good functional outcome at discharge. Motor weakness at presentation, GCS of 9 or less and mental status disorder were the strongest independent predictors of mortality at last follow-up among patients with CVT. Conclusions: Important differences were identified as compared to western data including younger age, high frequency of anemia, low use of OCP, and high frequency of hypercoaguable states. Functional outcome at discharge was good.

Older patients are significantly more likely to have colon ischaemia-associated conditions that are chronic and complex.

Colon ischaemia is a common disease which has been associated with various medications and comorbidities. To test the hypothesis that there are differences in the frequencies of these associations in older compared with younger patients. A retrospective cohort study was performed of patients hospitalized with colon ischaemia at two major medical centres from 2005-2017. Clinical, colonoscopic and pathologic criteria were used to identify patients admitted with colon ischaemia; patients with other types of colitis were excluded. Demographic and medical data were extracted. Two cohorts were created: patients aged 18-64years and patients>65years. These were compared using SAS 14.3. A total of 788 patients were included, of which 271 (34.4%) were of ages 18-64years, and 517 (66.6%) were 65years old or older. In the older cohort, constipation-inducing medications (83.8% vs 64.1%; P=<0.0001), diuretics (38.1% vs 25.1%; P=<0.001) and nonsteroidal anti-inflammatory drugs (58% vs 41.5%; P=<0.0001) were more common than in the younger cohort. Antipsychotic medication use was more common in the younger cohort (10.4% vs 5.4%; P=0.01). There was a higher percentage of younger patients with a history of hypercoaguable state (1.9% vs 0.2%; P=0.03) and dialysis dependence (22.9% vs 8.7%; P=<0.01), while a higher percentage of patients in the older cohort had a history of chronic obstructive pulmonary disease (12% vs 6.3%; P=0.01) or atrial fibrillation (18.9% vs 10.3%; P=<0.01). Our study shows that older patients are more likely to have colon ischaemia-associated conditions that are chronic and complex, while younger patients are more likely to have acute colon ischaemia-associated conditions.

Contemporary outcomes of thoracofemoral bypass

ObjectiveThoracofemoral bypass (TFB) is an alternative to aortofemoral bypass (AFB) or extra-anatomic bypass for severe aortoiliac occlusive disease (AIOD). TFB may be particularly useful in select patients with concurrent visceral aortic branch vessel disease, infrarenal aortic occlusions, or after failed AFB. However, there are few contemporary series describing the indications and outcomes for TFB. Therefore, the purpose of this analysis was to review our experience with TFB. MethodsAll patients undergoing TFB for occlusive disease from 2002 to 2017 were reviewed. All patients underwent left thoracoretroperitoneal exposure of the supraceliac aorta with division of the diaphragmatic crus and supraceliac cross-clamping. An end-to-side aortic anastomosis was created and each graft limb was tunneled in the retroperitoneum to the femoral bifurcation. Adjunctive visceral/infrainguinal revascularization was performed selectively based on symptoms, end-organ function, and/or preoperative imaging. The primary end points were major complications and 30-day mortality. Secondary end points included limb patency, freedom from major adverse limb events, and survival. Kaplan-Meier methodology was used to characterize the end points. ResultsForty-one patients (age 61 ± 9 years; 54% female; 7% in a hypercoaguable state) underwent TFB. The mean preoperative ankle-brachial index was 0.4 bilaterally. Indications included critical limb ischemia (56%), claudication (30%), acute limb ischemia (7%), and combined AIOD and mesenteric ischemia (7%). Seven patients (17%) had previously undergone AFB and 15 (38%) had previously undergone any prior aortic operation. Adjunctive visceral bypass occurred in 8 patients (20%; N = 14 grafts, n = 6 renal, n = 5 superior mesenteric artery, and n = 3 celiac). The postoperative duration of stay was 11 days (interquartile range [IQR], 7-16 days) and the 30-day mortality was 5% (n = 2). Major complications occurred in 34% of patients (N = 14; pulmonary, 15%; cardiac, 12%; bleeding, 7%; accidental splenectomy, 5%; renal, 5%; wound, 2%). The mean postoperative ankle-brachial index was 0.9 bilaterally. At a median follow-up of 7 months (IQR, 1-17 months), 5 patients (12%) underwent some form of reintervention (graft/limb related, n = 4 [n = 2 graft thrombosis, n = 2 graft infection], n = 1 mesenteric bypass revision). The estimated 3-year primary limb patency and freedom from major adverse limb events were 80 ± 10%, and 70 ± 10%, respectively. The estimated 5-year survival was 93 ± 5% (median, 27.3; IQR, 14.5-35.2; 95% confidence interval, 17.9-32.8). ConclusionsThis experience represents one of the largest and most current series of retroperitoneal TFB. We demonstrate that TFB can be performed with good outcomes for patients with severe AIOD, especially if concomitant visceral/infrainguinal reconstruction is warranted. These results support a continued role for TFB in select patients.

Dermal Regenerative Template as a Cost-Effective Alternative for Complex Scalp Reconstruction.

Use of dermal regeneration template (DRT) is well documented in the literature for complex wounds ranging from the scalp, trunk, and lower extremity. A retrospective cohort study was performed of the use of dermal regeneration template and skin grafting. A literature review was performed of all studies where DRT was used for scalp reconstruction. Patients in the DRT cohort had an average age of 70, with wounds averaging 108 cm in size. These patients also had a relatively low rate of complications (0.4), a short hospital stay (average 2 days), and a relatively short operating room time (114 minutes). This study demonstrates dermal regeneration template to be an effective and reliable option for soft tissue reconstruction with minimal morbidity and complications in patients with extensive medical comorbidities. Emerging applications include radiation exposure and hypercoaguable states.

Ovarian Vein Thrombus: Is Treatment Necessary?

BackgroundOvarian vein thrombus (OVT) has been described in patients with numerous comorbidities and is often an incidental finding on imaging. Prior studies have failed to draw a consensus regarding the best treatment for OVT. The purpose of this study is to evaluate if patient outcomes change based on treatment and to examine if anticoagulation duration affects resolution of OVT.MethodsThis study utilized a retrospective chart review to identify patients with OVT. Patients who carried any diagnosis containing the words "clot" or "thrombus" from January 2010 to May 2015 in the Penn Medicine system were included in the study. If a patient was identified as having an OVT based on radiologic findings, the following data was extracted from her chart: race, age at diagnosis, date of diagnosis, family history of thrombus, hypercoaguable work up, laterality of OVT, if OVT was occlusive, extension into adjacent veins, history of prior thrombus, context of diagnosis, treatment used, length of treatment, complications, and date of last contact.ResultsOf the 1436 patients identified during the inclusion period, 50 subjects with OVT were identified. The average age at diagnosis was 43.4 years. Fifty-six percent of subjects were African American and 38 percent were Caucasian. Sixty percent of OVT were located within the right gonadal vein, 14 percent were bilateral, and 24 percent were isolated to the left gonadal vein. Thirty eight percent of OVT were occlusive, eight percent extended into adjacent veins, and seven subjects had thrombi identified within alternative locations at the time of OVT diagnosis. Based on presumed etiology of OVT, patients were subdivided into eight categories as follows: active malignancy, peri- partum or post-partum, recent surgery, remote surgery, hypercoaguable state, active infection, incidental finding, and unknown. Eleven subjects received no treatment, one was treated with aspirin alone, three were treated with anticoagulation and antibiotics, and 32 patients were given anticoagulation alone. Three subjects had IVC filters placed at various times after presentation.Average length of follow up was 23.7 months (1- 108 months). Average length of anticoagulation was 13.2 weeks (3.5- 36 weeks). Two patients developed thrombi following treatment completion. Ten patients had imaging showing resolution of OVT after anticoagulation, while two patients who received no anticoagulation had radiographically confirmed resolution of OVT. Five patients treated with therapeutic anticoagulation exhibited persistent OVT following treatment, while four patients who did not receive anticoagulation had persistent OVT on follow up imaging. No statistically significant difference was identified in complication rate or resolution of OVT when comparing between patients who received treatment and those who did not receive treatment.ConclusionsSimilar to prior studies, we found that most patients had right sided OVT, and most OVT were found in the context of malignancy, pregnancy, the post- partum period, or post- operatively. There was no statistically significant correlation found between treatment and no treatment in terms of overall outcomes for patients diagnosed with OVT. Based on our findings, unless an OVT is symptomatic or septic in nature, an incidentally detected OVT does not necessarily warrant anticoagulation therapy. DisclosuresNo relevant conflicts of interest to declare.