Increase In Bleeding Complications Research Articles

Safety and efficacy of anticoagulation therapy post atrial fibrillation ablation

Abstract Funding Acknowledgements None. Background Thromboembolic complications can be life-threatening during atrial fibrillation (AF) catheter ablation. The aim of our single center, retrospective study was to evaluate the safety and efficacy of continuous treatment using direct oral anticoagulants (DOACs) as an alternative to uninterrupted acenocoumarol for periprocedural anticoagulation. Purpose To record the safety and efficacy of the oral anticoagulants post atrial fibrillation ablation. Methods We studied 1999 patients undergoing AF catheter ablation between June 2013 and December 2021 in our center. All patients were assigned to take acenocoumarol (group 1, 194 patients) or DOACs (group 2, 1805 patients) for ≥2 months before the procedure. We compared thromboembolic and bleeding complications between the 2 groups. Results Our analysis showed no significant difference in major and minor complications between the 2 patient groups with the exception of the occurrence of groin hematoma with a clear superiority of DOACs (2.06%-0.5%, p<0.05). Specifically, 4 of 194 patients (2.06%) using uninterrupted acenocoumarol had a major complication (3 patients [1.55%] had transient ischemic attack resolved 8 hours later and 1 [0.52%] had pericardial tamponade, and 7 patients (3.61%) had minor complications (4 [2.06%] groin hematoma and 3 [1.55%] mild pericardial efussion). In group 2, 14 of 1805 patients (0.78%) had a major complication (11 patients had transient ischemic attack (0.61%) and 3 patients (0.17%) had pericardial tamponade). In the same group, 31 patients (1.72%) had a minor complication (3 patients [0.17%] presented with pseudoaneurysm or femoral arteriovenous fistula between the femoral artery and femoral vein, 19 [1.05%] with pericardial effusion <1 cm, and 9 [0.5%] groin hematoma). Conclusions DOACs and acenocoumarol have similar safety and effectiveness regarding thromboembolic complications prevention without increasing bleeding complications with the exception of the occurrence of groin hematoma with a clear superiority of DOACs.

Treatment of Aorto-iliac and Infrainguinal Vascular Infections with a Prefabricated Bovine Pericardial Graft

The use of biological grafts provides acceptable mid- and long-term results in native or prosthetic vascular infections. Several reports describe the successful use of bovine pericardium in case of vascular infections, mainly as a large patch to be sutured as a tubular graft. Recently, a novel prefabricated bovine pericardium graft (Biointegral Surgical No-React® Inc, Mississauga, ON, Canada) has been introduced in clinical practice with promising results. In this study, we report our preliminary experience utilizing Biointegral Surgical graft in case of native and or prosthetic aorto-iliac and infrainguinal infection. We retrospectively analyzed data from 20 patients with native or prosthetic aorto-iliac and infrainguinal infection who underwent in situ reconstruction (ISR) with a Biointegral Surgical No-React bovine pericardium prosthesis between October 2020 and February 2023 at the Vascular Surgery Unit of the Fondazione Policlinico Universitario Gemelli - IRCCS in Rome, Italy. All patients followed a standardized protocol including postoperative anticoagulation and long-term intravenous antibiotics. The indication for surgery was: mycotic aortic aneurysm in 4 patients (20%), graft infection after abdominal aortic repair in 11 patients (55%), peripheral graft infection in 5 patients (25%). Complete excision of the infected aorta or prosthetic graft, surgical debridement and ISR were performed in all patients. Hospital mortality rate was 5% (n=1) and graft-related mortality of 0%. During follow-up (median 13months, range 6-34months), reinfection was 5.2% and primary graft patency 94.7%. The use of prefabricated bovine pericardial grafts represents a promising option for the treatment of native and prosthetic aorto-iliac and infrainguinal infections. The application of this biological graft with a standardized postoperative protocol has been associated with a satisfactory patency and reinfection rate without increased bleeding complications.

When is it safe to start thromboprophylaxis after splenic angioembolization?

BackgroundThromboprophylaxis after blunt splenic trauma is complicated by the risk of bleeding, but the risk after angioembolization is unknown. We hypothesized that earlier thromboprophylaxis initiation was associated with increased bleeding complications without mitigating venous thromboembolism events. MethodsAll blunt trauma patients who underwent splenic angioembolization within 24 hours of arrival were identified from the American College of Surgeons Trauma Quality Improvement Program datasets from 2017 to 2019. Cases with <24-hour length of stay, other serious injuries, and surgery before angioembolization were excluded. Venous thromboembolism was defined as deep vein thrombosis or pulmonary embolism. Bleeding complications were defined as splenic surgery, additional embolization, or blood transfusion after thromboprophylaxis initiation. Data were compared with χ2 analysis and multivariate logistic regression at P < .05. ResultsIn 1,102 patients, 84% had American Association for the Surgery of Trauma grade III to V splenic injuries, and 73% received thromboprophylaxis. Splenic surgery after angioembolization was more common in those with thromboprophylaxis initiation within the first 24 hours (5.7% vs 1.7%, P = .007), whereas those with the initiation of thromboprophylaxis after 72 hours were more likely to have a pulmonary embolism (2.3% vs 0.2%, P = .001). Overall, venous thromboembolism increased considerably when thromboprophylaxis was initiated after day 3. In multivariate analysis, time to thromboprophylaxis initiation was associated with bleeding (odds ratio 0.74 [95% confidence interval 0.58–0.94]) and venous thromboembolism complications (odds ratio 1.5 [95% confidence interval 1.20–1.81]). ConclusionThis national study evaluates bleeding and thromboembolic risk to elucidate the specific timing of thromboprophylaxis after splenic angioembolization. Initiation of thromboprophylaxis between 24 and 72 hours achieves the safest balance in minimizing bleeding and venous thromboembolism risk, with 48 hours particularly serving as the ideal time for protocolized administration.

Surgical Thromboprophylaxis in Patients With Head and Neck Cancer: An Economic Model.

To quantify postoperative venous thromboembolism (VTE) incidence in head and neck cancer (HNC) patients, and assess the economic implications of chemoprophylaxis. Retrospective cost-effective analysis. Fifty-threehealth care organizations. The TriNetX Research Network was queried to identify the 1-month VTE rate in HNC patients undergoing neck dissection from 2012 to 2022. A literature search provided additional postsurgical VTE rates in HNC patients. Costs of prophylactic heparin and enoxaparin were obtained from a drug wholesaler, and VTE-associated medical costs were sourced from the literature. A break-even analysis determined the absolute risk reduction (ARR) in the VTE rate necessary for a medication to break-even on cost. In TriNetX, 8193 HNC surgical patients underwent neck dissection, and an additional 1640 patients underwent neck dissection plus free flap reconstruction without chemoprophylaxis. Respective 1-month VTE rates were 1.3% (n = 103) and 2.5% (n = 41). Four additional studies of 1546 postoperative HNC patients not prescribed chemoprophylaxis reported a mean VTE rate of 3.8% (n = 59), ranging from 1.9% to 13.0%. At $8.40 per week, heparin resulted in cost savings if it decreased the VTE rate by an ARR of at least 0.05%, while enoxaparin, at $23.66 per week, needed to achieve a 0.14% ARR. Considering potential added costs from bleeding complications, heparin, and enoxaparin remained cost-effective if chemoprophylaxis did not increase bleeding complications by an absolute risk of more than 2.86% and 2.79%, respectively. Postoperative VTE rates varied in HNC patients. Despite this, achievable ARRs suggested the potential cost-effectiveness of routine chemoprophylaxis with heparin and enoxaparin.

Early Pharmacologic Therapy in Patients With Blunt Cerebrovascular Injury and TBI: Is it Safe and Effective? An EAST Multicenter Study.

Blunt cerebrovascular injury (BCVI) with concurrent traumatic brain injury (TBI) presents increased risk of both ischemic stroke and bleeding. This study investigated the safety and survival benefit of BCVI treatment (antithrombotic and/or anticoagulant therapy) in this population. We hypothesized that treatment would be associated with fewer and later strokes in patients with BCVI and TBI without increasing bleeding complications. Patients with head AIS >0 were selected from a database of BCVI patients previously obtained for an observational trial. A Kaplan-Meier analysis compared stroke survival in patients who received BCVI treatment to those who did not. Logistic regression was used to evaluate for confounding variables. Of 488 patients, 347 (71.1%) received BCVI treatment and 141 (28.9%) did not. BCVI treatment was given at a median of 31h post-admission. BCVI treatment was associated with lower stroke rate (4.9% vs 24.1%, P < .001 and longer stroke-free survival (P < .001), but also less severe systemic injury. Logistic regression identified motor GCS and BCVI treatment as the only predictors of stroke. No patients experienced worsening TBI because of treatment. Patients with BCVI and TBI who did not receive BCVI treatment had an increased rate of stroke early in their hospital stay, though this effect may be confounded by worse motor deficits and systemic injuries. BCVI treatment within 2-3days of admission may be safe for patients with mean head AIS of 2.6. Future prospective trials are needed to confirm these findings and determine optimal timing of BCVI treatment in TBI patients with BCVI.

Evidence-Based Approaches to Anticoagulation in Reconstructive Microsurgery-A Systematic Literature Review.

This systematic review addresses the crucial role of anticoagulation in microsurgical procedures, focusing on free flap reconstruction and replantation surgeries. The objective was to balance the prevention of thrombotic complications commonly leading to flap failure, with the risk of increased bleeding complications associated with anticoagulant use. A meticulous PubMed literature search following Evidence-Based-Practice principles yielded 79 relevant articles, including both clinical and animal studies. The full-texts were carefully reviewed and evaluated by the modified Coleman methodology score. Clinical studies revealed diverse perioperative regimens, primarily based on aspirin, heparin, and dextran. Meta-analyses demonstrated similar flap loss rates with heparin or aspirin. High doses of dalteparin or heparin, however, correlated with higher flap loss rates than low dose administration. Use of dextran is not recommended due to severe systemic complications. In animal studies, systemic heparin administration showed predominantly favorable results, while topical application and intraluminal irrigation consistently exhibited significant benefits in flap survival. The insights from this conducted systematic review serve as a foundational pillar towards the establishment of evidence-based guidelines for anticoagulation in microsurgery. An average Coleman score of 55 (maximum 103), indicating low overall study quality, however, emphasizes the need for large multi-institutional, randomized-clinical trials as the next vital step.

Vascular thrombosis after pediatric liver transplantation: Is prevention achievable?

BackgroundVascular thromboses (VT) are life-threatening events after pediatric liver transplantation (LT). Single-center studies have identified risk factors for intra-abdominal VT, but large-scale pediatric studies are lacking. MethodsThis multicenter retrospective cohort study of isolated pediatric LT recipients assessed pre- and perioperative variables to determine VT risk factors and anticoagulation-associated bleeding complications. ResultsWithin seven postoperative days, 31/331 (9.37%) patients developed intra-abdominal VT. Open fascia occurred more commonly in patients with VT (51.61 vs 23.33%) and remained the only independent risk factor in multivariable analysis (OR = 2.84, p = 0.012). Patients with VT received more blood products (83.87 vs 50.00%), had significantly higher rates of graft loss (22.58 vs 1.33%), infection (50.00 vs 20.60%), and unplanned return to the operating room (70.97 vs 16.44%) compared to those without VT. The risk of bleeding was similar (p = 0.2) between patients on and off anticoagulation. ConclusionsProphylactic anticoagulation did not increase bleeding complications in this cohort. The only independent factor associated with VT was open fascia, likely a graft/recipient size mismatch surrogate, supporting the need to improve surgical techniques to prevent VT that may not be modifiable with anticoagulation.

Can Risk-Based Thromboprophylaxis Practice Guidelines be Safely Used in Esophagectomy Cases? Experience of an Academic Health System

BackgroundVenous thromboembolism (VTE) occurs in 3–11% of esophagectomy patients and is associated with increased mortality and morbidity. The use of validated VTE risk assessment tools and compliance with recommended practice guidelines remains unclear. In this study, we seek to determine the use of Caprini guideline indicated VTE prophylaxis and its effect on VTE and bleeding complications following esophagectomy. MethodsEsophagectomy cases were identified from the Mayo Clinic electronic health records. Caprini score and VTE prophylaxis regimen received were determined retrospectively. VTE prophylaxis was identified as appropriate or inappropriate based on the Caprini score and prophylaxis received preoperative, during hospitalization, and after hospital discharge. Study cohorts were compared by Pearson Chi-square test, Fisher’s Exact test, Kruskal–Wallis test, and logistic regression models. Stata/MP 16.1 was used for analysis. Odds ratios and 95% confidence intervals were reported for logistic regression models. A p-value < 0.05 was considered significant. ResultsFour hundred and fifty-six esophagectomy cases were analyzed. The median Caprini score was thirteen. Appropriate prophylaxis resulted in a 6.9-fold reduction in inpatient VTE. All 30- and 90-day post-discharge VTEs occurred in those not receiving Caprini guideline-indicated VTE prophylaxis. Inpatient, 30- and 90-day post-discharge bleeding rates were 7.68%, 0.91%, and 2.11%, respectively; however, bleeding was not increased with receipt of appropriate prophylaxis. ConclusionIn this esophagectomy cohort, Caprini guideline indicated VTE prophylaxis resulted in reduced inpatient VTE events without increasing bleeding complications. Risk-based VTE prevention measures should be considered in this patient cohort known to be at heightened risk for postoperative VTE.

Venous thromboembolism in multiple myeloma: Increasing evidence in support of direct oral anticoagulants.

Venous thromboembolism (VTE) continues to cause significant morbidity and excess mortality in patients with multiple myeloma. The report by Costa and colleagues demonstrates superiority of direct oral anticoagulants over aspirin in terms of VTE prevention, without increased bleeding complications seen. Commentary on: Costa et al. Direct oral anticoagulants versus aspirin for primary thromboprophylaxis in patients with multiple myeloma undergoing outpatient therapy: A systematic review and updated meta-analysis. Br J Haematol 2023;203:395-403.

A Contemporary Review of Antiplatelet Therapies in Current Clinical Practice.

Antiplatelet therapy plays a crucial role in a number of cardiovascular disorders. We currently have a range of antiplatelet agents in our armamentarium. In this review, we aim to summarise the common antiplatelet agents currently available, and their use in clinic practice. We not only highlight recent trials exploring antiplatelet therapy in atherosclerotic cardiovascular disease, but also in trials related to transcatheter aortic valve implantation and coronavirus disease 2019. Inevitably, the antithrombotic benefits of these drugs are accompanied by an increase in bleeding complications. Therefore, an individualised approach to weighing each patient's thrombotic risk versus bleeding risk is imperative, in order to improve clinical outcomes.

The Limit Is Zero: A Prospective Evaluation of Ketorolac in Patients Undergoing Primary Palatoplasty to Reduce Narcotic Utilization.

Patients undergoing primary palatoplasty rely on narcotics for pain control, but narcotics can lead to sedation and respiratory depression. Recent research into Enhanced Recovery After Surgery (ERAS) pathways utilizing multimodal pain therapy has yielded promising results for patients undergoing palatoplasty in terms of decreased hospital length of stay (LOS), increased oral intake, and decreased narcotic usage. Despite the potential benefit of ketorolac after palatoplasty, there is a paucity of data regarding its use. A single-center cohort study of patients undergoing primary palatoplasty was performed using 2 cohorts: a retrospective cohort treated with our institution's prior ERAS protocol from 2016 to 2018 and a prospective group of patients who also received ketorolac (ERAS+K) postoperatively from 2020 to 2022. A total of 85 patients (57 ERAS and 28 ERAS+K) were included. Compared with the ERAS group, the ERAS+K cohort had significantly decreased LOS (31.8 versus 55 h, P =0.02), decreased morphine milligram equivalents administered at 24 hours (1.5 versus 2.5, P =0.003), 48 hours (0 versus 1.5, P <0.001), and total inpatient morphine milligram equivalents (1.9 versus 3.8, P =0.001). The ERAS+K group also had a significant decrease in the prescribed narcotic rate (32.1% versus 61.4%, P =0.006). No bleeding issues, blood transfusions, or reoperations were noted in either cohort. This study illustrates many potential benefits of using ketorolac as a pain management adjunct in combination with a multimodal pain regimen. Our results demonstrated favorable outcomes, including decreased narcotic usage and LOS as well as increased hourly oral intake, without increasing bleeding complications.

Low Molecular Weight Heparin Is Superior for Venous Thromboembolism Prophylaxis in High-Risk Geriatric Patients.

Venous thromboembolism (VTE) is a source of preventable morbidity and mortality in critically ill trauma patients. Age is one independent risk factor. Geriatric patients embody a population at high thromboembolic and hemorrhagic risk. Currently, there is little guidance between low molecular weight heparin (LMWH) and unfractionated heparin (UFH) for anticoagulant prophylaxis in the geriatric trauma patient. A retrospective review was conducted at an ACS verified, Level I Trauma center from 2014 to 2018. All patients 65years or older, with high-risk injuries and admitted to the trauma service were included. Choice of agent was at provider discretion. Patients in renal failure, or those that received no chemoprophylaxis, were excluded. The primary outcomes were the diagnosis of deep vein thrombosis or pulmonary embolism and bleeding associated complications (gastrointestinal bleed, TBI expansion, hematoma development). This study evaluated 375 subjects, 245 (65%) received enoxaparin and 130 (35%) received heparin. DVT developed in 6.9% of UFH patients, compared to 3.3% with LMWH (P = .1). PE was present in 3.8% of UFH group, but only .4% in the LMWH group (P = .01). Combined rate of DVT/PE was significantly lower (P = .006) with LMWH (3.7%) compared to UFH (10.8%). 10 patients had documented bleeding events, and there was no significant association between bleeding and the use of LMWH or UFH. VTE events are more common in geriatric patients treated with UFH compared to LMWH. There was no associated increase in bleeding complications when LMWH was utilized. LMWH should be considered the chemoprophylatic agent of choice in high risk geriatric trauma patients.

PD40-02 ASSOCIATION BETWEEN ORAL ANTITHROMBOTIC DRUGS USE AND BLEEDING IN PARTIAL NEPHRECTOMY: A RETROSPECTIVE COHORT STUDY

You have accessJournal of UrologyCME1 Apr 2023PD40-02 ASSOCIATION BETWEEN ORAL ANTITHROMBOTIC DRUGS USE AND BLEEDING IN PARTIAL NEPHRECTOMY: A RETROSPECTIVE COHORT STUDY Yuzhe Tang, José Nolazco, Zhiyu (Jason) Qian, Marie-Thérèse Valovska, Kendrick Yim, Benjamin Chung, and Steven Chang Yuzhe TangYuzhe Tang More articles by this author , José NolazcoJosé Nolazco More articles by this author , Zhiyu (Jason) QianZhiyu (Jason) Qian More articles by this author , Marie-Thérèse ValovskaMarie-Thérèse Valovska More articles by this author , Kendrick YimKendrick Yim More articles by this author , Benjamin ChungBenjamin Chung More articles by this author , and Steven ChangSteven Chang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003345.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Whether perioperative period oral antiplatelet (AP) and anticoagulant (AC) drugs use can lead to bleeding in PN is controversial. This study analyzes the association between oral AP/AC use and bleeding complications in partial nephrectomy in a large cohort. METHODS: Using the Premier Hospital Database, we performed a retrospective cohort study of patients undergoing partial nephrectomy to manage kidney cancer and renal masses from 2003 to 2020. The study cohort was limited to adult patients undergoing elective surgery. Using administrative codes and billing, we assessed for an association between AP/AC drug use and bleeding complication using mixed-effects multiple logistic regression models controlling for a wide range of clinical-demographic, surgical, and hospital factors. The primary outcome was bleeding within 90 days in or after surgery. Secondary outcomes were mortality rate 90 days after surgery and length of hospital stay. RESULTS: The study cohort comprised 48,112 partial nephrectomy patients, of which 10.9% had bleeding complications. Mixed-effects multivariable logistic regression models revealed that AP was associated with 31% increased odds for bleeding (OR 1.31; 95% CI: 1.15-1.49; p<0.01) and AC was associated with 2.25 times odds for bleeding compared with none users (OR 2.25; 95% CI: 1.85-2.74; p<0.01), AP and AC combination group was associated with the most bleeding risk (OR 3.09; 95% CI: 2.q4-4.74; p<0.01). An effect modification of oral AP drug use and Myocardial infarction (MI) history was detected, which is shown in Figure 1. The relationship between surgeon volume and bleeding risk was presented as a "J" shape (Figure 2). More than 33 cases/year for PN surgeons entered a plateau phase and slightly increased the bleeding risk. CONCLUSIONS: AC/AP use is associated with a significant increase in bleeding complications following partial nephrectomy surgery; Compared with AP, AC induces more probability of bleeding; AP and AC combination lead to even more bleeding risk. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1051 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yuzhe Tang More articles by this author José Nolazco More articles by this author Zhiyu (Jason) Qian More articles by this author Marie-Thérèse Valovska More articles by this author Kendrick Yim More articles by this author Benjamin Chung More articles by this author Steven Chang More articles by this author Expand All Advertisement PDF downloadLoading ...

Sex Differences Among Patients Receiving Edoxaban vs Vitamin K Antagonist for Atrial Fibrillation After TAVR

BackgroundIn the ENVISAGE-TAVI AF (Edoxaban vs Standard of Care and Their Effects on Clinical Outcomes in Patients Having Undergone Transcatheter Aortic Valve Implantation–Atrial Fibrillation) trial, edoxaban was noninferior to vitamin K antagonists (VKA) for a composite outcome of ischemic and bleeding complications but increased major bleeding in patients with atrial fibrillation after successful transcatheter aortic valve replacement. Women are at higher risk of bleeding and stroke than men after transcatheter aortic valve replacement. It is unclear whether the effect of edoxaban on these complications varies in relation to sex. ObjectivesThis study was to assess the effect of edoxaban vs VKA according to sex in the ENVISAGE-TAVI AF trial. MethodsThe primary outcomes were net adverse cardiovascular events (NACE) and major bleeding, assessed considering the effective time on study medication (safety analysis). ResultsOut of 1,377 patients, 658 (47.8%) were women. Risks for ischemic and major bleeding outcomes were similar between women and men. Edoxaban compared to VKA was associated with a similar risk of NACE in women (HR: 1.16; 95% CI: 0.81-1.65) and men (HR: 1.08; 95% CI: 0.76-1.53; P for interaction = 0.820) and a higher risk of major bleeding in both sexes (P for interaction = 0.170). The risk increase of major bleeding was attenuated in women (HR: 1.11; 95% CI: 0.69-1.79) as compared to men (HR: 1.75; 95% CI: 1.07-2.85). There were no treatment-related differences for ischemic complications in both sexes. ConclusionsEdoxaban compared to VKA was associated with a similar risk of NACE and higher risk of major bleeding in both sexes. The increase in bleeding complications with edoxaban was attenuated in women.

Risk adjusted venous thromboembolism prophylaxis following pancreatic surgery.

This study analyzes pancreatectomy cases performed between 2016 and 2021 to determine the impact of using Caprini guideline indicated VTE prophylaxis on VTE and bleeding complications. This is a retrospective study of cases performed in a single academic health care system, in which Caprini score and VTE prevention measures were determined retroactively and prevention practices binarized as appropriate or not appropriate. Univariate and multivariate analyses were performed of 1,299 pancreatectomy case. Most patients were stratified as high risk for postoperative VTE. Receiving appropriate VTE prophylaxis during admission was associated with a 3-fold reduction in VTE complications (0.82% vs. 2.64%, p=0.01) without increasing bleeding complications. All VTE complications occurring with 30-day (1.2%) and 90-day (2.7%) from hospital discharged occurred in those not receiving appropriate prophylaxis, and discharged bleeding complications were also not associated with receivng appropriate discharged VTE prophylaxis. The findings our the study are significant as it highlights the ongoing need for standardization in VTE risk assessment and prevention measures to increase compliance to risk adjusted VTE prevention practice guidelines, thus reducing preventable VTE complications and potentially associated morbidity and mortality.

Providing best practices for the management of ST-segment elevation myocardial infarction (STEMI): Pharmacoinvasive strategies

Although primary PCI remains the preferred strategy for the treatment of STEMI, the lack of expanded PCI centers and prolonged transfer times have resulted in delayed reperfusion and thus increased mortality. A pharmacoinvasive strategy involving immediate fibrinolysis followed by transfer to a PCI center to perform angiography (and PCI of infarct-related arteries) within 2 and 24 hours after successful fibrinolysis offers immediate reperfusion and better outcomes in patients in whom primary PCI could not be achieved in a timely manner without an increase in bleeding complications. The article summarizes the evidence for this approach in terms of efficacy and safety.

1020: THERAPEUTIC ENOXAPARIN IN MORBIDLY OBESE PATIENTS: SINGLE-CENTER EXPERIENCE

Introduction: Enoxaparin is a low molecular weight heparin commonly used in the treatment of venous thromboembolisms (VTEs); however, evidence on optimal therapeutic dosing recommendations and bleeding adverse events are lacking in patients with morbid obesity (BMI > 35). Recommendation for VTE is 1 mg/kg every 12 hours using total body weight (TBW) for all patients. Methods: We performed a retrospective chart review of patients who were admitted to the ICU between 1/2020 and 9/2021 and were treated for VTE with 1 mg/kg TBW enoxaparin (full dose, FD) to look at bleeding complication rates in patients with BMI >35 and compared with patients who received 0.5 – 0.8 mg/kg TBW (adjusted dose, AD) and BMI > 35. Bleeding complications rates were defined as: needing one or more unit RBC transfusion (RBC), intracranial hemorrhage (ICH), retroperitoneal hemorrhage (RPH), or GI bleed (GIB). The following data were also collected from electronic medical records: Gender (Male), anti-Xa checked (AX), BMI (kg/m2), acute kidney injury (AKI based on KDIGO definitions), and hospital mortality. Results: We identified a total of 55 patients (42 in FD group and 13 in AD group). Compared to AD group, the FD group had more RBC transfusions (50% vs 31%), more ICH (7% vs 0 %), more RPH (9.5% vs 0 %), and more GIB (2.4 % vs 0%) respectively. Both groups were comparable regarding gender (M: 52 vs 38%, p = 0.4), anti-Xa (64% vs 62%, p = 0.9), BMI (44 +/- 7 vs 47 +/- 15, p = 0.3), AKI (17 % vs 15 %, p = 0.7), and mortality (29 % vs 31 %, p = 0.9). Conclusions: These data suggest that enoxaparin at recommended dosing of 1 mg/kg every 12 hours using total body weight for obese patients with BMI > 35 is associated with increased bleeding complications. These findings should be investigated in large multicenter prospective studies.

Coming soon to a pharmacy near you? FXI and FXII inhibitors to prevent or treat thromboembolism

Anticoagulants have been in use for nearly a century for the treatment and prevention of venous and arterial thromboembolic disorders. The most dreaded complication of anticoagulant treatment is the occurrence of bleeding, which may be serious and even life-threatening. All available anticoagulants, which target either multiple coagulation factors or individual components of the tissue factor (TF) factor VIIa or the common pathways, have the potential to affect hemostasis and thus to increase bleeding risk in treated patients. While direct oral anticoagulants introduced an improvement in care for eligible patients in terms of safety, efficacy, and convenience of treatment, there remain unmet clinical needs for patients requiring anticoagulant drugs. Anticoagulant therapy is sometimes avoided for fear of hemorrhagic complications, and other patients are undertreated due to comorbidities and the perception of increased bleeding risk. Evidence suggests that the contact pathway of coagulation has a limited role in initiating physiologic in vivo coagulation and that it contributes to thrombosis more than it does to hemostasis. Because inhibition of the contact pathway is less likely to promote bleeding, it is an attractive target for the development of anticoagulants with improved safety. Preclinical and early clinical data indicate that novel agents that selectively target factor XI or factor XII can reduce venous and arterial thrombosis without an increase in bleeding complications.

Feasibility and outcomes with subclavian vein access for crescent jugular dual lumen catheter for venovenous extracorporeal membrane oxygenation in COVID-19 related acute respiratory distress syndrome.

Femoral-femoral Veno-Venous ExtraCorporeal Life Support (V-V ECLS) has been associated with higher infections rates, vascular site bleeding complications, and restricted patient mobility. Jugular or bicaval dual lumen V-V ECLS conceptually overcomes some of these adverse factors, but experience has shown that jugular vein cannulation still limits mobility and has increased bleeding complications. Technique and outcomes of subclavian vein single-cannulation with Crescent jugular dual-lumen V-V ECLS is described. five patients with COVID-19 related acute respiratory distress syndrome (ARDS) underwent right subclavian vein V-V ECLS placement with the Crescent 32 French jugular dual-lumen V-V ECLS catheter. A standardized percutaneous technique was developed that allowed efficient insertion without need for any specialized imaging (i.e. transesophageal echocardiogram) and outcomes assessed. Mean age of the five patients was 41.2years, all obese with an average basal mass index of 45.2kg/m2 and mean days to decannulation of 24.2days. Outcomes discovered included; improved patient mobility allowing physical rehabilitation, no vascular access site related complications requiring surgery or endovascular intervention, and none had evidence of superior vena cava syndrome. One patient had subclavian/axillary vein thrombosis with resolution after 3months of direct-acting oral anticoagulants, and one patient had blood cultures positive at day 37, nearing decannulation. Subclavian vein access for crescent jugular dual lumen V-V ECLS catheter appears to be safe and feasible with added benefits of decreased bleeding and increased mobility over jugular or femoral-femoral access site for long term V-V ECLS support in COVID-19 related ARDS patients.

Abstract 15628: Incidence, Complications, and Outcomes of Non - ST Elevation Myocardial Infarction in Patients Presenting With Acute Ischemic Stroke

Background: Acute myocardial infarction may concomitantly occur with acute ischemic stroke. The incidence,complications and outcomes of acute Non- ST elevation Myocardial infarction in acute ischemic stroke are not well studied. Methods: We examined hospitalized patients (n = 1,726,265) with acute ischemic stroke that were included in National Inpatient Sample 2016-2019. Acute ischemic stroke and NSTEMI were defined by using International classification of disease (ICD -10). STEMI patients were excluded. Multivariable logistic regression analysis was used to examine association of NSTEMI with outcomes. A subgroup analysis of NSTEMI patients that underwent PCI (with or without angioplasty) was also performed. Results: Of the total stroke patients, 27630 (1.6%) patients (mean age 73.5, 52.2% females) had NSTEMI diagnosed during the hospitalization. Of these, 3890 (6.32%) died in NSTEMI group and 57670 (93.68%) died in non NSTEMI group. The commonest complications in NSTEMI group were cardiogenic shock 25% , cardiac tamponade 13.8% , and septic shock 12.1%. NSTEMI in stroke patients were associated with several complications and mortality (OR 2.73, 95% CI 2.57-2.90, p value &lt;0.001). While, PCI was performed in 43.3% of NSTEMI patients, there was no increase in bleeding complications and there was reduced risk of mortality associated with PCI (OR 0.34, 95% CI 0.22-0.52, p&lt;0.001)[FIGURE]. Conclusion: NSTEMI even though not frequent in patients with stroke but was associated with increased risk of complications and mortality. PCI was associated with reduced risk of mortality and no increase in bleeding complications.