Multiple Risk Factors For Thrombosis Research Articles

Serial Peripheral Nerve Blocks to Aid in Salvage of a Compromised Limb: A Case Report.

The management of postsurgical thrombosis in a medically complicated patient is often not straightforward. We describe a case of a congenital heart disease patient with multiple risk factors for thrombosis with a compromised limb immediately after heart transplant who received serial daily peripheral nerve blocks (PNBs) resulting in limb salvage. The analgesic effects of the blocks allowed for clinical progression and participation in rehabilitation therapy, and the vasodilatory effects of the blocks helped prevent a below the knee amputation (BKA) in this devitalized and congested extremity.

P708 Multimodality imaging of catheter-related right atrial thrombus: a case report

Abstract INTRODUCTION Catheter-related right atrial thrombosis (CRAT) is potentially life-threatening complication of long-term indwelling central venous catheters (CVC), which are used extensively in various patients. Reported incidence of CRAT is variable (2-62%) and probably underestimated due to predominantly asymptomatic course and lack of routine screening. Main pathogenic mechanisms that promote CRAT include mechanical and chemical injury of atrial endocardium by the catheter and infused drugs, stasis of blood and hypercoaguability. Differential diagnosis between thrombus and other intracardiac masses, especially myxoma, is sometimes very difficult and requires multimodality imaging studies. CASE PRESENTATION 62-years old patient after chemotherapy of lymphoma, in remission, with subcutaneous CVC inserted in right subclavian vein, which was used as chemotherapy port several years ago, was sent to emergency department because right atrial mass was found on elective outpatient transthoracic echocardiography (TTE). Urgent computed tomography (CT) was performed and showed well defined, 1.8 x 2.0 cm large, low attenuating mass with some calcifications. Several features were primarily suggestive of myxoma, however differentiation from thrombus was not possible. Patient was admitted to hospital, where transesophageal echocardiography (TEE) confirmed the presence of heterogenous mass attached to right atrial free wall with tumor-like movement. Mobile catheter tip was nearby and touching the mass irregularly. Although in addition to CT also some echocardiographic characteristics were more consistent with myxoma, there was still high clinical suspicion of CRAT due to multiple risk factors for thrombosis. Cardiac magnetic resonance imaging (MRI) using cine sequence was performed for further evaluation and revealed mobile, homogeneously low-signal intensity mass that remained hypointense on contrast-enhanced sequences (first pass perfusion and late gadolinium enhancement), which led to final diagnosis of thrombus. CONCLUSION CRAT should be suspected and anticipated in all, also asymptomatic patients with long-term indwelling CVC (e.g. for chemotherapy, parenteral nutrition, hemodialysis..), majority of whom have additional multiple risk factors for thrombosis. Routine screening for CRAT can provide early diagnosis and treatment and should be considered especially in high-risk patients in order to prevent potentially severe complications. Although echocardiography is the modality of choice for screening, further imaging modalities, e.g. CT and MRI are often required to differentiate thrombus from myxoma or other cardiac masses. Our case demonstrates difficult differential diagnosis of right atrial mass in an asymptomatic patient with a long-term indwelling chemotherapy port, in whom multimodality imaging studies were performed, but only MRI with contrast-enhanced sequences providing superior tissue characterization, could differentiate between CRAT and myxoma. Abstract P708 Figure. Multimodality imaging of atrial thrombus

Open heart surgery for management of right auricular thrombus related to central venous catheterization

Abstract Central venous catheters are widely used in critically ill patients; however, they are also associated with increased morbidity and mortality. The literature may underestimate the incidence of catheter-inducible right atrial thrombi that are asymptomatic but potentially life threatening. The recognized risk factors for its development include infections related to the catheter, endothelial injury secondary to mechanical and chemical damage induced by certain medications and infused fluids. The characteristics of the patient and the catheter, such as size, material, type, location and ease of insertion, as well as the duration of placement play an additional role. We report the case of a 38-year-old man, who developed an asymptomatic catheter-inducible right atrial thrombi requiring open-heart surgery, after taking a central venous catheter for thirty-five days. The present case highlights existing limitations in making a correct and fast diagnosis, which should be anticipated in patients with multiple risk factors for thrombosis. Given the limited recommendations available, we consider that the most appropriate strategy should be individualized.

Risk Factors and Management of Venous Thromboembolic Diseases in Donor of Living Donor Liver Transplant

Background: liver transplantation surgically replaces a failing or diseased liver with one that is normal and healthy. At this time, transplantation is the only cure for liver insufficiency or liver failure because no device or machine reliably performs all of the functions of the liver. Aim of the Work: this study aimed to highlight risk factors of the venous thromboembolism in donors of living donor liver transplant and its management. Patients and Methods: this study included 40 patients who underwent hepatectomy for living donor liver transplant. All patients were evaluated extensively, including history and physical examination and specialty consultations when indicated. All patients did haematological studies to detect the risk factors of thromboembolic disease. Results: in patients with manifestations of venous thromboembolism 2 donors have single risk factor for venous thromboembolism and 4 donors have double risk factors. Conclusion: presence of multiple risk factors for venous thromboembolism led to increase in its incidence, so during preoperative assessment of the donors, if they have multiple risk factors for thrombosis some precautions should be taken to avoid venous thrombosis. Recommendations: preoperative precautions include heamatological consultations for the donors and prophylaxis dose of anticoagulant. Intra operative precautions included pneumatic calf pressure, elastic stocking. Finally postoperative precautions should be continued , these donors should take therapeutic doses of anticoagulants and follow up by lower limb venous duplex.

Endovascular Management of May–Thurner Syndrome in Adolescents: A Single-Center Experience

PurposeTo report a single-center experience in regard to the technique, safety, and clinical outcomes of endovascular therapy for treatment of May–Thurner syndrome (MTS) in adolescent patients. Materials and MethodsA retrospective review identified 10 patients (6 female; mean age, 16 y; range, 12–18 y; mean weight, 73 kg; range, 50–116 kg) treated by endovascular therapy for MTS from 1998 to 2015. Clinical presentations consisted of acute thrombotic MTS (n = 6) and nonthrombotic MTS (n = 4). Catheter‐directed thrombolysis was performed in all cases of thrombosis. Venoplasty and stent placement were performed in all cases. Self-expanding stents 12–16 mm in diameter and 4–9 cm in length were deployed. ResultsNo major periprocedural complications were observed. Median follow-up was 32 months (range, 6–109 mo). Primary and secondary patency rates were 79% and 100% at 12 months and 79% and 89% at 36 months, respectively. In a single patient with permanent loss of flow in the treated segment, multiple risk factors for thrombosis were identified. Rates of posttreatment symptoms were 0% by Villalta score and 60% (n = 6; mild symptoms) by modified Villalta score at the last clinical follow-up. ConclusionsEndovascular therapy for the treatment of MTS in our adolescent cohort was safe and effective in relieving venous obstruction. Stent placement in patients with underlying thrombophilic disorders is associated with loss of secondary patency, suggesting the need for further consideration in this population.

Drug-Induced Thrombophilic or Prothrombotic States: An Underestimated Clinical Problem That Involves Both Legal and Illegal Compounds.

Vascular thrombosis, both arterial and venous, is a condition associated with significant morbidity and mortality. There are multiple risk factors for thrombosis, both congenital and acquired, and in the majority of cases, these risk factors are not modifiable. Over the past 2 decades, multiple drugs (both illegal and legal) have been associated with increased risk of thrombosis. However, due to limited scientific literature regarding the prothrombotic tendencies of these drugs, there is a concomitant limited understanding of the pathophysiology of drug-induced thrombosis. As drugs are one of the few modifiable risk factors for thrombosis, further study and dissemination of knowledge regarding drug-associated and drug-induced thrombosis are essential and have the potential to lead to decreased future incidence of thrombosis. The mechanisms at the basis of the thrombophilic activity of these drugs are variable and sometimes still ill recognized. Increased levels of clotting factors, reduction in coagulation natural inhibitors, decreased fibrinolysis, activated clotting factors, increased blood viscosity, endothelial damage, and increased platelet number and activation are the most frequent causes. Arterial steal or coronary arteries no flow has also been implicated. In some cases due to the intake of several drugs, more than one mechanism is present in a given patient. The purpose of the present review is to analyze all the drugs demonstrated to be potentially thrombotic. It is hoped that a prudent use or nonuse of these drugs might result in a reduction of thrombosis-associated diseases.

Optic Nerve Sheath Fenestration for the Treatment of Papilledema Secondary to Cerebral Venous Thrombosis

A 16-year-old adolescent girl with multiple risk factors for thrombosis presented with acute onset of headache, decreased vision, and papilledema. Evaluation demonstrated cerebral venous thrombosis (CVT) involving the left transverse and sigmoid sinuses and left internal jugular vein. Following bilateral optic nerve sheath fenestration (ONSF), she experienced improvement in vision and resolution of papilledema. In selected cases, ONSF is an effective surgical option for the treatment of papilledema due to CVT after medical treatment has failed.

Percutaneous recanalization of central veins access for pacemaker/cardioverter–defibrillator implantation or upgrade

To report a single-center experience in regard to the technique, safety, and clinical outcomes of endovascular therapy for treatment of May–Thurner syndrome (MTS) in adolescent patients.A retrospective review identified 10 patients (6 female; mean age, 16 y; range, 12–18 y; mean weight, 73 kg; range, 50–116 kg) treated by endovascular therapy for MTS from 1998 to 2015. Clinical presentations consisted of acute thrombotic MTS (n = 6) and nonthrombotic MTS (n = 4). Catheter‐directed thrombolysis was performed in all cases of thrombosis. Venoplasty and stent placement were performed in all cases. Self-expanding stents 12–16 mm in diameter and 4–9 cm in length were deployed.No major periprocedural complications were observed. Median follow-up was 32 months (range, 6–109 mo). Primary and secondary patency rates were 79% and 100% at 12 months and 79% and 89% at 36 months, respectively. In a single patient with permanent loss of flow in the treated segment, multiple risk factors for thrombosis were identified. Rates of posttreatment symptoms were 0% by Villalta score and 60% (n = 6; mild symptoms) by modified Villalta score at the last clinical follow-up.Endovascular therapy for the treatment of MTS in our adolescent cohort was safe and effective in relieving venous obstruction. Stent placement in patients with underlying thrombophilic disorders is associated with loss of secondary patency, suggesting the need for further consideration in this population.

Efficacy, Safety and Tolerability of E5501 (AKR501) In a 6-Month Extension Study In Subjects with Chronic Immune Thrombocytopenia (ITP).

Efficacy, Safety and Tolerability of E5501 (AKR501) In a 6-Month Extension Study In Subjects with Chronic Immune Thrombocytopenia (ITP).

Evaluation of Bleeding and Thrombotic Events during Long-Term Use of Romiplostim in Patients with Chronic Immune Thrombocytopenic Purpura.

Immune thrombocytopenic purpura (ITP) is an autoimmune hematologic disorder of increased platelet destruction and sub-optimal platelet production. Patients (pts) often have low platelet counts (<50 x 109/L) and present with bleeding, purpura, and petechiae; at very low counts, there is a risk of spontaneous intracranial or other life-threatening bleeding. Romiplostim is an investigational thrombopoiesis-stimulating Fc-peptide fusion protein (peptibody) that increases platelet production via binding to and activating the megakaryocyte thrombopoietin receptor.Objective: This study evaluated bleeding and thrombotic events (TEs) occurring in adults with ITP treated with romiplostim during two phase III, randomized, placebo-controlled, 24-week studies, and an open-label extension study. Patients with platelet counts <50 x 109/L were eligible to enter the extension study in which all pts received romiplostim; rates of bleeding events (up to 48 weeks of treatment) and TEs (up to 84 weeks) for these pts were analyzed.Results: In the phase III trials, 84 pts received weekly subcutaneous injections of romiplostim (initial dose 1μg/kg, dose adjusted to maintain platelet counts of 50–200x109/L) and 41 pts received placebo. 115 pts completed the phase III trials, and 101 pts (romiplostim N=68; placebo N=33) entered the extension study. Bleeding events were captured as adverse events (AEs) and graded according to severity. Clinically significant bleeding AEs (i.e. severity grade ≥2 or higher, where 2= moderate, 3=severe, 4=life-threatening, or 5=fatal) were noted in 16% of romiplostim- and 34% of placebo-treated patients (P=0.018). The percentage of pts experiencing bleeding AEs ≥ grade 3 severity was 7% and 12% in the romiplostim and placebo groups, respectively (P=0.36) None of the pts with bleeding events ≥ grade 3 had achieved a durable platelet response (defined by platelet count of ≥50x 109/L during at least 6 of the last 8 weeks of treatment). No bleeding AEs ≥ grade 3 occurred in pts with platelet counts >20 x 109/L while no bleeding AEs of grade ≥2 occurred at counts >50 x 109/L. During the extension study, the percentage of pts with a bleeding AE of any severity decreased from 36% (Weeks 1–12) to 12% (Weeks 36–48). The percentage of pts with bleeding AEs of grade 2 or higher severity decreased steadily from 16% (Weeks 1–12) to 5% (Weeks 37–48). In the phase III studies, the incidence of TEs was 2.4% in both the romiplostim and placebo groups. In the romiplostim group, one patient had a cerebrovascular accident while another had a right popliteal arterial embolism; one placebo-treated patient had a fatal pulmonary embolism. During the extension study, 7 additional TEs occurred in four more pts (patient incidence: 4%): one patient with coronary artery occlusion; one with a calf vein thrombosis; two pts with multiple events. Platelet counts at the time of TEs in all studies ranged from 3 x 109/L to 948 x 109/L. Seven of the 10 TEs occurred at counts below the median peak platelet count for all pts treated with romiplostim in both the phase III and extension studies (167 x 109/L). Furthermore all pts who experienced thrombotic AEs had multiple risk factors for thrombosis including congestive heart failure, antiphospholipid antibodies, coronary artery disease, hypertension, cancer, and/or a history of thrombotic events.Conclusion: Romiplostim appears to be an efficacious and well-tolerated treatment for adults with chronic ITP. The severity of bleeding events decreased during short-term (24-weeks) treatment, and long-term (up to 48 weeks) treatment resulted in further decreases in severe bleeding AEs and overall bleeding frequency. Thrombosis occurred in pts with risk factors, but did not appear to be related to higher than normal platelet counts.

Abnormalities of homocysteine and B vitamins in the nephrotic syndrome

Introduction The nephrotic syndrome is associated with heightened risk for arterial and venous thrombosis. Multiple derangements of hemostasis and acquired risk factors such as hyperlipidemia and hypertension contribute to this risk. The prevalence in the nephrotic syndrome of high circulating levels of homocysteine and of low levels of the B vitamins that are involved in its metabolism, which may play a role in thrombosis, is not well defined. Materials and methods In 84 patients with nephrotic syndrome and 84 sex- and age-matched controls, hemostasis variables and the circulating levels of total homocysteine (tHcy), vitamin B 6, B 12 and folates were measured. Results tHcy levels were higher, vitamin B 6 and vitamin B 12 levels were lower in nephrotic patients than in controls. The association of low vitamin B 6 levels with the nephrotic syndrome was independent of any other alteration associated with the disease. Eighty-two percent of patients with the nephrotic syndrome had vitamin B 6 levels falling in the lowest quartile of the normal distribution. Antithrombin deficiency, factor V Leiden, antiphospholipid antibodies, hypertension, dyslipidemia, were more frequent in patients with the nephrotic syndrome than in controls. Conclusions Patients with the nephrotic syndrome have multiple risk factors for thrombosis. We report that they frequently have low circulating levels of vitamin B 6, which associate with a heightened risk for venous and arterial thrombosis.

PULMONARY EMBOLISM AND PREMATURE LABOR IN A PATIENT WITH BOTH FACTOR V LEIDEN MUTATION AND METHYLENETETRAHYDROFOLATE REDUCTASE GENE C677T MUTATION

Multiple risk factors for thrombosis were found in a 21 year old female who experienced three episodes of premature labor and developed severe pulmonary embolism during her third pregnancy. This patient is heterozygous for factor V Leiden mutation and homozygous for methylenetetrahydrofolate reductase (MTHFR) gene nucleotide 677 C to T (C677T) point mutation. This is a first report of the concordance of homozygous MTHFR C677T mutation in an individual with factor V Leiden mutation. This new case provides further evidence that synergism of multiple genetic and acquired risk factors is often encountered in young patients with symptomatic venous thrombosis.