Perioperative Anticoagulation Research Articles

Efficacy and Safety of Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation Undergoing Elective Surgical Procedures: A Meta-analysis.

Objective: The study objective was to determine if peri-operative bridging anticoagulation in patients with atrial fibrillation is beneficial or harmful.Design: Systematic review and meta-analysis.Setting: Inpatient or in-hospital setting.Participants: Adults with atrial fibrillation having a CHADS2 score >1 undergoing elective surgical procedure on anticoagulation.Methods: A systemic search of multiple databases (Cochrane, Medline, PubMed) was performed regarding studies conducted on efficacy and safety of perioperative bridging anticoagulation in patients with atrial fibrillation. Studies identified were reviewed by two authors individually before inclusion. The results were then pooled using Review Manager to determine the combined effect. Stroke/systemic embolism was considered as the primary efficacy outcome. Major bleeding was the primary safety outcome.Results: The systematic search revealed 108 potential articles. The full texts of 28 articles were retrieved for assessment of eligibility. After full text review, 25 articles were excluded. Three articles met inclusion criteria. No significant difference in stroke/systemic embolism with bridging anticoagulation was noted (risk ratio, 1.25-95% confidence interval [CI], 0.55-2.85). Bridging was associated with significantly higher risk of major bleeding (risk ratio, 3.29-95% CI, 2.25-4.81).Conclusion: An individualized approach is required when initiating peri-operative bridging anticoagulation. There is certainly a higher risk of bleeding with bridging anticoagulation and no difference in stroke/systemic embolism. However, the results cannot be extrapolated to patients who have valvular atrial fibrillation or CHADS2 score of 5 or greater.

Dynamic changes of coagulation and fibrinolytic biomarkers in peri operaive arthroplasty patients.

To evaluate coagulation and fibrinolytic parameters after total joint arthroplasty (TJA) and provide evidence for optimization of timing of perioperative anticoagulation medicine. The prospective study was conducted at the Jishuitan Hospital of Peking University from January to April in 2016, and comprised patients who were scheduled consecutively to undergo primary total knee arthroplasty (TKA) or total hip arthroplasty (THA). Blood samples were obtained at day 1 preoperatively and day1, day 3 postoperatively. Antigenic levels of protein C (PC), endothelial protein C receptor (EPCR), tissue factor pathway inhibitor (TFPI), antithrombin III (AT-III), plasminogen activator inhibitor 1 (PAI-1) and tissue plasminogen activator (tPA) were measured with commercially available enzyme-linked immunosorbent assay kits. Postoperative levels of coagulation parameters TFPI and AT-III were increased compared to preoperative values (118.7±34.6 vs 70.0±20.5 μg/ml for AT-III, and 26.37±7.91vs 16.68±8.92 μg/l for TFPI), while postoperative levels of coagulation parameters PC and EPCR were decreased (0.88±0.30 vs 2.03±0.66 μg/ml for PC, and 100.8±31.0 vs 199.4±57.4 μg/ml for EPCR). Postoperative levels of fibrinolytic parameter tPA was increased compared to preoperative values (2.87±0.83 vs 2.03±1.03 μg/l), while its specific inhibitor PAI-1 was decreased (0.88±0.30 vs 2.03±0.66 μg/l). These results demonstrated the perturbation of the coagulation and fibrinolytic system of patients undergoing TJA. Hypercoagulation and hyperfibrinolysis were observed in postoperative patients, which suggested anticoagulant therapy is effective and necessary.

Predictors of Bleeding in the Perioperative Anticoagulant Use for Surgery Evaluation Study.

BackgroundIn the PAUSE (Perioperative Anticoagulant Use for Surgery Evaluation) Study, a simple, standardized, perioperative interruption strategy was provided for patients with nonvalvular atrial fibrillation taking direct oral anticoagulants (DOACs). Our objective was to define the factors associated with perioperative bleeding.Methods and ResultsWe analyzed bleeding as the composite of major and clinically relevant nonmajor bleeding. Putative predictors of bleeding, and preoperative DOAC level were prospectively collected during recruitment. We used stratified logistic regression models for analysis. All statistical analyses were performed in R version 3.6.0. There were 3007 patients requiring perioperative DOAC interruption. More than one third of the included patients underwent a high bleeding risk procedure. The 30‐day rates of major and clinically relevant nonmajor bleeding were 3.02% in apixaban (n=1257), 2.84% in dabigatran (n=668), and 4.16% for rivaroxaban (n=1082). Multivariate analysis stratified by region found more bleeding for hypertension (odds ratio [OR], 1.79; 95% CI 1.07‐2.99; P=0.027), and prior bleeding (OR, 1.71; 95% CI, 1.08‐2.71; P=0.021). Surgical bleed risk classification (high‐ versus low‐risk) as a predictor of bleeding was only significant in the univariate analysis. The prediction model for major and clinically relevant nonmajor bleeding had an area under the curve of 0.71, and the preoperative DOAC level did not improve the area under the curve of the model.ConclusionsIn patients treated with DOACs who required an elective surgery/procedure and were managed with standardized DOAC interruption and resumption, there we did not find reversible risk factors for bleeding, suggesting that adjustment of the PAUSE management protocol to mitigate against bleeding is not needed.

Perioperative anticoagulation in patients with intracranial meningioma: No increased risk of intracranial hemorrhage?

Anticoagulation (AC) is a critical topic in perioperative and post-bleeding management. Nevertheless, there is a lack of data about the safe, judicious use of prophylactic and therapeutic anticoagulation with regard to risk factors and the cause and modality of brain tissue damage as well as unfavorable outcomes such as postoperative hemorrhage (PH) and thromboembolic events (TE) in neurosurgical patients. We therefore present retrospective data on perioperative anticoagulation in meningioma surgery. Data of 286 patients undergoing meningioma surgery between 2006 and 2018 were analyzed. We followed up on anticoagulation management, doses and time points of first application, laboratory values, and adverse events such as PH and TE. Pre-existing medication and hemostatic conditions were evaluated. The time course of patients was measured as overall survival, readmission within 30 days after surgery, as well as Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS). Statistical analysis was performed using multivariate regression. We carried out AC with Fraxiparin and, starting in 2015, Tinzaparin in weight-adapted recommended prophylactic doses. Delayed (216 ± 228h) AC was associated with a significantly increased rate of TE (p = 0.026). Early (29 ± 21.9h) prophylactic AC, on the other hand, did not increase the risk of PH. We identified additional risk factors for PH, such as blood pressure maxima, steroid treatment, and increased white blood cell count. Patients' outcome was affected more adversely by TE than PH (+3 points in modified Rankin Scale in TE vs. +1 point in PH, p = 0.001). Early prophylactic AC is not associated with an increased rate of PH. The risks of TE seem to outweigh those of PH. Early postoperative prophylactic AC in patients undergoing intracranial meningioma resection should be considered.

Predictors of preprocedural direct oral anticoagulant levels in patients having an elective surgery or procedure

AbstractThe Perioperative Anticoagulation Use for Surgery Evaluation (PAUSE) study prospectively evaluated a prespecified periprocedural-interruption strategy of direct oral anticoagulants (DOACs) among patients with atrial fibrillation. Logistic regression analyses were performed to identify clinical parameters associated with residual DOAC levels ≥30 ng/mL or ≥50 ng/mL. Patients undergoing low-bleed-risk procedures were more likely to have residual levels of ≥30 ng/mL and ≥50 ng/mL. For low-risk procedures, age ≥75 years, female sex, a creatinine clearance (CrCl) <50 mL/min, and an interruption of <36 hours were associated with a greater likelihood of levels ≥30 ng/mL, whereas age ≥75 years, female sex, a CrCl of <50 mL/min, and standard DOAC dosing were associated with levels ≥50 ng/mL. For high-risk procedures, weight of <70 kg, CrCl <50 mL/min, and standard DOAC dosing were associated with residual levels ≥30 ng/mL, whereas female sex was associated with levels ≥50 ng/mL. For low-risk procedures, apixaban was associated with a higher likelihood of levels ≥30 ng/mL as compared with dabigatran (P = .0019) and of levels ≥50 ng/mL when compared with rivaroxaban (P = .0003). For high-risk procedures, apixaban was marginally associated with a higher likelihood of residual levels ≥30 ng/mL when compared with dabigatran (P = .05), whereas rivaroxaban was associated with a higher likelihood of levels ≥30 ng/mL as compared with apixaban. Further study is required to determine whether adjustments to perioperative plans based on these clinical parameters could result in a lower risk of residual DOAC levels. The PAUSE trial was registered at www.clinicaltrials.gov as #NCT2228798.

Perioperative Antithrombotic Therapy Management and Venous Thromboembolism Prophylaxis

The management of perioperative anticoagulation, antiplatelet therapy, and perioperative venous thromboembolism (VTE) prophylaxis is essentially a balancing act between patient risk factors for thrombosis and surgical risk factors for bleeding. The purpose of this review is to assist surgeons with the identification of patients at increased risk for thromboembolism when antithrombotic therapy is interrupted, patients for whom bridging anticoagulation should be considered, patients who require perioperative VTE prophylaxis, and patients at increased risk for bleeding complications and to briefly review the literature and major guidelines regarding perioperative antithrombotic therapy management and perioperative VTE prophylaxis. Figures show approaches to the management of perioperative anticoagulation, antiplatelet therapy, and VTE prophylaxis. This review contains 2 figures, 7 tables, and 61 references. Keywords: Venous thromboembolism, pulmonary embolism, anticoagulation, surgery, perioperative period, prophylaxis

Perioperative Antithrombotic Therapy Management and Venous Thromboembolism Prophylaxis

The management of perioperative anticoagulation, antiplatelet therapy, and perioperative venous thromboembolism (VTE) prophylaxis is essentially a balancing act between patient risk factors for thrombosis and surgical risk factors for bleeding. The purpose of this review is to assist surgeons with the identification of patients at increased risk for thromboembolism when antithrombotic therapy is interrupted, patients for whom bridging anticoagulation should be considered, patients who require perioperative VTE prophylaxis, and patients at increased risk for bleeding complications and to briefly review the literature and major guidelines regarding perioperative antithrombotic therapy management and perioperative VTE prophylaxis. Figures show approaches to the management of perioperative anticoagulation, antiplatelet therapy, and VTE prophylaxis. This review contains 2 figures, 7 tables, and 61 references. Keywords: Venous thromboembolism, pulmonary embolism, anticoagulation, surgery, perioperative period, prophylaxis

Perioperative Antithrombotic Therapy Management and Venous Thromboembolism Prophylaxis

The management of perioperative anticoagulation, antiplatelet therapy, and perioperative venous thromboembolism (VTE) prophylaxis is essentially a balancing act between patient risk factors for thrombosis and surgical risk factors for bleeding. The purpose of this review is to assist surgeons with the identification of patients at increased risk for thromboembolism when antithrombotic therapy is interrupted, patients for whom bridging anticoagulation should be considered, patients who require perioperative VTE prophylaxis, and patients at increased risk for bleeding complications and to briefly review the literature and major guidelines regarding perioperative antithrombotic therapy management and perioperative VTE prophylaxis. Figures show approaches to the management of perioperative anticoagulation, antiplatelet therapy, and VTE prophylaxis. This review contains 2 figures, 7 tables, and 61 references. Keywords: Venous thromboembolism, pulmonary embolism, anticoagulation, surgery, perioperative period, prophylaxis

A perioperative bivalirudin anticoagulation protocol for neonates with congenital diaphragmatic hernia on extracorporeal membrane oxygenation

IntroductionThere is little published data regarding bivalirudin anticoagulation for surgical neonates on extracorporeal membrane oxygenation (ECMO). This study described our perioperative anticoagulation protocol and evaluated the relationship of bivalirudin dose to activated partial thrombin time (aPTT) and thromboelastography reaction time (TEG-R) monitoring assays. Materials and methodsNeonates with congenital diaphragmatic hernia (CDH) on ECMO and single-agent bivalirudin anticoagulation at our institution from 2016 to 2018 were included. Bivalirudin infusion rates, laboratory results, transfusions, and clinical events during the initial (cannulation to repair) and postoperative (up to 60 h post-repair) periods were recorded. ResultsForty-two neonates met inclusion criteria. Bivalirudin was started at 0.16 mg/kg/h and titrated in 10–20% increments to target aPTT of 70–85 s and TEG-R of 9–12 min. All patients achieved target anticoagulation levels within the first 12 h on doses ranging from 0.12–0.36 mg/kg/h. Postoperatively, bivalirudin increased to median 0.16 (range 0.08–0.40), 0.22 (0.08–0.60), and 0.39 (0.08–0.80) mg/kg/h by 6, 24, and 60 h, respectively. On multivariable regression, no significant association of aPTT (p = 0.09) or TEG-R (p = 0.22) with bivalirudin dose was seen. Hemoglobin decrease ≥2 g/dL in 24 h occurred in 39%, but there were no reoperations, deaths, or circuit changes for thrombosis. ConclusionsThis standardized perioperative bivalirudin protocol achieved target anticoagulation level quickly. Postoperative bleeding was managed without significant morbidity. Consistent dose-response relationships between bivalirudin and aPTT or TEG-R were not seen, but gradually increasing doses were needed to maintain therapeutic anticoagulation.

Perioperative outcomes of interrupted anticoagulation in patients with non-valvular atrial fibrillation undergoing non-cardiac surgery

BackgroundThis study aimed to investigate the incidences of and risk factors for perioperative events following anticoagulant discontinuation in patients with non-valvular atrial fibrillation (NVAF) undergoing non-cardiac surgery.MethodsA total of 216 consecutive patients who underwent cardiac consultation for suspending perioperative anticoagulants were enrolled. A perioperative event was defined as a composite of thromboembolism and major bleeding. ResultsThe mean anticoagulant discontinuation duration was 5.7 (±4.2) days and was significantly longer in the warfarin group (p<0.001). Four perioperative thromboembolic (1.9%; three strokes and one systemic embolization) and three major bleeding events (1.4%) were observed. The high CHA2DS2-VASc and HAS-BLED scores and a prolonged preoperative anticoagulant discontinuation duration (4.4±2.1 vs. 2.9±1.8 days; p=0.028) were associated with perioperative events, whereas the anticoagulant type (non-vitamin K antagonist oral anticoagulants or warfarin) was not. The best cut-off levels of the HAS-BLED and CHA2DS2-VASc scores were 3.5 and 2.5, respectively, and the preoperative anticoagulant discontinuation duration for predicting perioperative events was 2.5 days. Significant differences in the perioperative event rates were observed among the four risk groups categorized according to the sum of these values: risk 0, 0%; risk 1, 0%; risk 2, 5.9%; and risk 3, 50.0% (p<0.001). Multivariate logistic regression analysis showed that the HAS-BLED score was an independent predictor for perioperative events. ConclusionThromboembolic events and major bleeding are not uncommon during perioperative anticoagulant discontinuation in patients with NVAF, and interrupted anticoagulation strategies are needed to minimize these.

Effect of Direct Oral Anticoagulant, Patient, and Surgery Characteristics on Clinical Outcomes in the Perioperative Anticoagulation Use for Surgery Evaluation Study.

Introduction The Perioperative Anticoagulation Use for Surgery Evaluation (PAUSE) Study assessed a standardized perioperative management strategy in patients with atrial fibrillation who were taking a direct oral anticoagulant (DOAC) and required an elective surgery or procedure. The aim of this substudy is to analyze the safety of this management strategy across different patient subgroups, according to four presurgical variables: (1) DOAC type and dose, (2) surgery/procedure bleed risk, (3) patient renal function, and (4) age. Methods Clinical outcomes analyzed included major bleeding (MB), arterial thromboembolism, any bleeding, and any thromboembolism. We used descriptive statistics to summarize clinical outcomes, where the frequency, proportion, and 95% confidence interval were reported. Fisher's exact tests were used for testing the null hypothesis of independence between the clinical outcome and patient characteristic, where the test p -values were reported. Results There were 3,007 patients with atrial fibrillation requiring perioperative DOAC management. There was no significant difference in bleeding or thromboembolic outcomes according to DOAC type/dose regimen, renal function, or patient age. The rate of MB was significantly higher with high bleed risk procedures than low bleed risk procedures in apixaban-treated patients (2.9 vs. 0.59%; p < 0.01), but not in dabigatran-treated patients (0.88 vs. 0.91%; p = 1.0) or rivaroxaban-treated patients (2.9 vs. 1.3%; p = 0.06). The risk for thromboembolism did not differ according to surgery/procedure-related bleed risk. Conclusion Our results suggest that in DOAC-treated patients who received standardized perioperative management, surgical bleed risk is an important determinant of bleeding but not thromboembolic outcomes, although this finding was not consistent across all DOACs. There were no differences in bleeding and thromboembolism according to DOAC type and dose, renal function, or age.

Performance of First Rib Resection by Vascular Surgeons for Thoracic Outlet Syndrome Minimizes Hemorrhagic Complications

Thoracic outlet syndrome (TOS) takes on heterogeneous upper extremity manifestations depending on whether the artery, vein, or brachial plexus is primarily compressed. Despite sharing a common mechanism, the operative and perioperative management of these distinct types of TOS is disparate. As a result of these variable vascular and neurogenic symptoms, patients present to surgeons of various training backgrounds for surgical decompression. Surgeon specialty is known to correlate with outcomes for numerous vascular procedures, but its role in TOS is unclear. In this work, we examine the impact of surgeon specialty on short-term outcomes of first rib resection (FRR) for TOS. Using the American College of Surgeons National Surgical Quality Improvement Program database, 3070 patients were identified who underwent FRR for TOS during 2006 to 2017. Arterial, venous, and neurogenic TOS types were distinguished with International Classification of Diseases, Ninth Revision and Tenth Revision codes; patient characteristics, provider specialty, and postoperative outcomes were classified through a combination of standard National Surgical Quality Improvement Program variables and International Classification of Diseases data. Data analysis was performed with Stata version 14.2 (StataCorp LP, College Station, Tex). Most FRRs were performed by vascular surgeons (87.9%), general surgeons (6.9%), and thoracic surgeons (4.4%). The practice patterns between the specialties were significantly different (P < .001), with non-vascular surgeons operating on a significantly more undifferentiated TOS than vascular surgeons (16.9% vs 4.4%) but not less arterial or venous TOS (1.1% vs 2.4% and 8.6% vs 9.1%, respectively). Patients who underwent FRR with non-vascular surgeons experienced more frequent rate of postoperative transfusion (3.2% vs 1.2%; P = .001) and wound infection (1.9% vs 0.8%; P = .04). On multivariate regression, patients receiving FRR for venous TOS were more likely to experience an episode of postoperative hemorrhage requiring transfusion (odds ratio, 3.63; 95% confidence interval [CI], 1.43-9.25). Patients operated on by surgeons whose specialty was not among the top three most common specialties performing FRR had a 40% longer length operative time (incidence rate ratio, 1.42; 95% CI, 1.15-1.74) as well as a significantly increased odds of requiring a transfusion (odds ratio, 9.87; 95% CI, 2.28-42.68). These results suggest that despite the fact that vascular surgeons have a TOS practice with equivalent increased vascular complexity compared with non-vascular surgeons, their postoperative hemorrhage rates are decreased. This is likely due to the independent association between venous TOS and postoperative hemorrhage and pertains to familiarity with perioperative anticoagulation management as well as operative factors. The significantly increased operative times and transfusion requirements independently associated with specialties that uncommonly perform FRR raise further questions about the role of surgeon experience and volume in this procedure.

The Utility of Therapeutic Anticoagulation in the Perioperative Period in Patients Presenting in Emergency Surgical Department With Extremity Vascular Injuries

Extremity vascular trauma is a challenging surgical emergency in both civilian population and combat environment. It requires vigilant diagnosis and prompt treatment to minimize limb loss and mortality. A multidisciplinary team approach is required to deal with shock states, concomitant abdominal injuries, head injuries, and fractures with significant tissue loss and psychological stress.Anticoagulation is frequently used during traumatic vascular repair to avoid repair site thrombosis, postoperative deep venous thrombosis, and pulmonary embolism (PE). In this review article, we are going to search about how frequent is the use of anticoagulation in terms of limb salvage rates, and mortality rates or side effects of anticoagulation in terms of risk of bleeding episodes, and the need for future prospective studies.Extremity vascular trauma is managed by a variety of methods including open repairs, endovascular repairs, and nonoperative management. Most of the literature demonstrates the use of systemic or regional anticoagulation in the management of vascular injuries with the improvement in limb salvage rates and reduced morbidities but confounding factors lead to variable results. Some studies show an increased risk of bleeding in trauma patients with the use of anticoagulants in trauma settings without any significant effect on repair site thrombosis. More comprehensive studies and randomized controlled trials are needed to confirm the importance of perioperative anticoagulation while avoiding the confounding factors in terms of injury severity scores, ischemia time, demographics of patients, modes of injury, comorbidities, grades of shock, concomitant injuries that need anticoagulation like venous injuries or intracranial injuries that are contraindications to the use of anticoagulation, type of anticoagulation and expertise available as well as the experience level of the operating surgeon. Literature also reveals the use of new oral anticoagulants (e.g., dabigatran) to be associated with lesser bleeding episodes when compared to warfarin, so in future, we can check the feasibility of these agents to reduce the bleeding episodes and at the same time improve the limb salvage rates.

Meta-analysis of efficacy and safety of new oral anticoagulants compared with warfarin in Japanese patients undergoing catheter ablation for atrial fibrillation.

This meta-analysis was designed to evaluate the efficacy and safety of new oral anticoagulants (NOACs) for perioperative anticoagulation of atrial fibrillation (AF) catheter ablation (CA) in Japanese patients with non-valvular atrial fibrillation (NVAF). PubMed, Embase, Web of Science, and the Cochrane Library were searched for articles published up to June 30, 2019. Two reviewers independently screened literature, extracted data, and assessed the methodological quality of the included studies according to the inclusion and exclusion criteria. Then, meta-analysis was performed using RevMan 5.3 software. Nineteen studies with a total of 6827 patients were included in this meta-analysis. The experimental group received dabigatran, rivaroxaban, apixaban, or edoxaban; the control group received warfarin. The safety endpoints were bleeding complications; the efficacy endpoints were thromboembolic complications. Results were as follows: Patients with NOACs had a lower risk of overall bleeding complications (OR = 0.69, 95% CI (0.54, 0.87), P= 0.002), including major bleeding complications (OR = 0.52, 95% CI (0.32, 0.84), P= 0.007) and minor bleeding complications (OR = 0.73, 95% CI (0.56, 0.94), P= 0.02). There was no significant difference in thromboembolic complications between NOACs and warfarin after CA (OR = 0.39, 95% CI (0.14, 1.10), P= 0.08). In Japanese NVAF patients undergoing CA, NOACs have similar effects to warfarin in the prevention of stroke and systemic embolism. Moreover, NOACs were associated with a lower incidence of bleeding complications.

Perioperative Anticoagulation Management in Spine Surgery: Initial Findings From the AO Spine Anticoagulation Global Survey.

Study Design:Cross-sectional, international survey.Objectives:This study addressed the global perspectives concerning perioperative use of pharmacologic thromboprophylaxis during spine surgery along with its risks and benefits.Methods:A questionnaire was designed and implemented by expert members in the AO Spine community. The survey was distributed to AO Spine’s spine surgeon members (N = 3805). Data included surgeon demographic information, type and region of practice, anticoagulation principles, different patient scenarios, and comorbidities.Results:A total of 316 (8.3% response rate) spine surgeons completed the survey, representing 64 different countries. Completed surveys were primarily from Europe (31.7%), South/Latin America (19.9%), and Asia (18.4%). Surgeons tended to be 35 to 44 years old (42.1%), fellowship-trained (74.7%), and orthopedic surgeons (65.5%) from academic institutions (39.6%). Most surgeons (70.3%) used routine anticoagulation risk stratification, irrespective of geographic location. However, significant differences were seen between continents with anticoagulation initiation and cessation methodology. Specifically, the length of a procedure (P = .036) and patient body mass index (P = .008) were perceived differently when deciding to begin anticoagulation, while the importance of medical clearance (P < .001) and reference to literature (P = .035) differed during cessation. For specific techniques, most providers noted use of mobilization, low-molecular-weight heparin, and mechanical prophylaxis beginning on postoperative 0 to 1 days. Conversely, bridging regimens were bimodal in distribution, with providers electing anticoagulant initiation on postoperative 0 to 1 days or days 5-6.Conclusion:This survey highlights the heterogeneity of spine care and accentuates geographical variations. Furthermore, it identifies the difficulty in providing consistent perioperative anticoagulation recommendations to patients, as there remains no widely accepted, definitive literature of evidence or guidelines.

MP74-12 THROMBOEMBOLIC EVENTS AFTER RADICAL PROSTATECTOMY IN PATIENTS WITH HEREDITARY THROMBOPHILIA DUE TO FACTOR V LEIDEN

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy IV (MP74)1 Apr 2020MP74-12 THROMBOEMBOLIC EVENTS AFTER RADICAL PROSTATECTOMY IN PATIENTS WITH HEREDITARY THROMBOPHILIA DUE TO FACTOR V LEIDEN Sophie Knipper*, Jonas Ekrutt, Pierre Tennstedt, Hans Heinzer, Derya Tilki, and Markus Graefen Sophie Knipper*Sophie Knipper* More articles by this author , Jonas EkruttJonas Ekrutt More articles by this author , Pierre TennstedtPierre Tennstedt More articles by this author , Hans HeinzerHans Heinzer More articles by this author , Derya TilkiDerya Tilki More articles by this author , and Markus GraefenMarkus Graefen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000960.012AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: With an incidence of about 5%, Factor V Leiden is the most common hereditary hypercoagulability among Caucasians. The increased risk of thromboembolic events is 5 to 8 fold in heterozygous and 10 to 25 fold in homozygous patients. In general, perioperative anticoagulation needs to be individualized, especially in oncological patients in whom pelvic surgery is planned. It is unknown if factor V Leiden patients may be at higher risk of thromboembolic events when treated with radical prostatectomy. METHODS: Within our prospectively collected database, we analyzed 30,871 prostate cancer patients treated with radical prostatectomy between 2001 and 2019. Of those, patients with factor V Leiden were identified. All patients received individualized recommendation of hemostaseologists for perioperative anticoagulation. Thromboembolic complications (deep vein thrombosis, pulmonary embolism) were assessed during hospital stay, as well as according to patient reported outcomes within the first three months after radical prostatectomy. RESULTS: Overall, 77 (0.3%) patients with known factor V Leiden were identified. Median age was 64 years (interquartile range: 61-68 years). Median follow-up was 37 months (IQR: 8-60 months). Within all 77 patients with factor V Leiden, none experienced thromboembolic complications within the first three months after surgery. CONCLUSIONS: In our cohort of patients with factor V Leiden, no thromboembolic events were observed after radical prostatectomy with individualized anticoagulation. This may reassure patients with this hereditary condition who are counselled for radical prostatectomy. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1136-e1136 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sophie Knipper* More articles by this author Jonas Ekrutt More articles by this author Pierre Tennstedt More articles by this author Hans Heinzer More articles by this author Derya Tilki More articles by this author Markus Graefen More articles by this author Expand All Advertisement PDF downloadLoading ...

MP32-14 CONTINUATION OF ANTIPLATELET AND/OR ANTICOAGULATION IN PATIENTS UNDERGOING REZūM PROSTATE ABLATION

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology II (MP32)1 Apr 2020MP32-14 CONTINUATION OF ANTIPLATELET AND/OR ANTICOAGULATION IN PATIENTS UNDERGOING REZūM PROSTATE ABLATION Ajay Gopalakrishna*, Raevti Bole, Ruby Kuang, David Yang, Matthew Houlihan, Masaya Jimbo, Sevann Helo, Matthew Ziegelmann, and Tobias Kohler Ajay Gopalakrishna*Ajay Gopalakrishna* More articles by this author , Raevti BoleRaevti Bole More articles by this author , Ruby KuangRuby Kuang More articles by this author , David YangDavid Yang More articles by this author , Matthew HoulihanMatthew Houlihan More articles by this author , Masaya JimboMasaya Jimbo More articles by this author , Sevann HeloSevann Helo More articles by this author , Matthew ZiegelmannMatthew Ziegelmann More articles by this author , and Tobias KohlerTobias Kohler More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000876.014AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Rezūm is a minimally invasive technique to treat benign prostatic hyperplasia (BPH). Major advantages include no de novo erectile dysfunction and low rate of retrograde ejaculation. Discontinuation of peri-operative antiplatelet and/or anticoagulation (APAC) is often preferred in practice to avoid bleeding complications. The objective of this study is to examine outcomes and complications in patients undergoing Rezūm on APAC. METHODS: We retrospectively reviewed patients who underwent Rezūm therapy at our institution since 7/2017. When deemed medically necessary, APAC was continued in the perioperative setting. Post-procedure catheterization regimen included a minimum of 3 days and a maximum of 4 weeks in men with preoperative catheter dependence. Outcomes included pre- and post-operative AUA symptoms score, peak flow, and postvoid residual. Bleeding-related complications and urinary tract infection rate were recorded. RESULTS: Of 214 patients who underwent Rezūm therapy, 68 patients were treated on APAC. The average prostate gland size was 73 grams. Significant improvements were seen in AUA symptom score, peak flow, and post void residual (Table 1). Bleeding complications requiring intervention occurred in 6 (9.3%) patients, with all 6 undergoing catheter irrigation, 2 undergoing blood transfusion, and 1 undergoing cystoscopic clot evacuation. Interestingly, 9/146 (6.3%) patients who were not on APAC had hematuria requiring intervention. There were no statistically significant differences in bleeding complications. There was no de novo erectile dyfunction reported. CONCLUSIONS: In our experience, bleeding complications in patients undergoing Rezūm on APAC is uncommon. There were no apparent differences in complication rates between patients on APAC and those not on APAC. To the best of our knowledge, this is the largest study to examine outcomes and complications of Rezūm in patients on APAC. Rezūm appears to be a safe and efficacious treatment option in men continuing APAC who wish to preserve sexual function. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e490-e490 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ajay Gopalakrishna* More articles by this author Raevti Bole More articles by this author Ruby Kuang More articles by this author David Yang More articles by this author Matthew Houlihan More articles by this author Masaya Jimbo More articles by this author Sevann Helo More articles by this author Matthew Ziegelmann More articles by this author Tobias Kohler More articles by this author Expand All Advertisement PDF downloadLoading ...

Bleeding Complications After Transoral Robotic Surgery: A Meta-Analysis and Systematic Review.

Postoperative hemorrhage is the most common complication of transoral robotic surgery (TORS), the severity of which can range from minor bleeding treated with observation to catastrophic hemorrhage leading to death. To date, little is known about the incidence, risk factors, and management of post-TORS hemorrhage. Systematic Review and Metanlysis. A systematic review of the published literature using the Cochrane Handbook for Systematic Reviews of Interventions was performed and examined TORS, postoperative hemorrhage, and the use of prophylactic transcervical arterial ligation (TAL). A total of 13 articles were included in the analysis. To date, there have been 332 cases of hemorrhage following a total of 5748 TORS. The pooled median post-TORS hemorrhage rate was 6.47%. The overall incidence of minor and major hemorrhage was 5.29% and 2.90%. Patients with prior radiation (relative risk [RR] = 1.46, 95% confidence interval [CI] = 1.00-2.12), large tumors (RR = 2.11, 95% CI = 1.48-2.99), and those requiring perioperative coagulation (RR = 2.25, 95% CI = 1.54-3.28) had significantly higher relative risks of hemorrhage. There was no significant difference in the relative risk of overall hemorrhage with TAL. Looking at major hemorrhage, patients undergoing TAL had a large but insignificant relative risk reduction in post-TORS hemorrhage (RR = 0.40, 95% CI = 0.15-1.07). The incidence of post-TORS hemorrhage is low (5.78%), and for major hemorrhage requiring emergent embolization, TAL, or tracheotomy to control hemorrhage it is even lower (2.90%). Large tumors, perioperative anticoagulation, and prior radiation were associated with significantly increased risk of post-TORS hemorrhage. TAL does not reduce the overall incidence of post-TORS hemorrhage but may lead to fewer severe hemorrhages. III Laryngoscope, 131:95-105, 2021.

Intravenous Leiomyomatosis of the Uterus: A Retrospective Single-Center Study in 14 Cases.

Purpose This study aimed to retrospectively review the diagnosis and surgical treatment of uterine intravenous leiomyomatosis (IVL). Methods The clinical data of 14 patients with uterine IVL admitted to our hospital between 2013 and 2018 were retrospectively analyzed, including their demographics, imaging results, surgical procedures, perioperative complications, and follow-up results. Results The tumors were confined to the pelvic cavity in 7 patients, 1 into the inferior vena cava, 4 into the right atrium, and 2 into the pulmonary artery (including 1 into the superior vena cava). Only one case was misdiagnosed as right atrial myxoma before the operation, which was found during the surgery and was treated by staging surgery; all the other patients underwent one-stage surgical resection. Three patients underwent complete resection of the right atrial tumor through the abdominal incision, and one patient died of heart failure in the process of resection of heart tumor without abdominal surgery. During the 6–60 months of follow-up, 4 patients developed deep venous thrombosis of the lower extremity, and 1 patient developed ovarian vein thrombosis and pulmonary embolism. After anticoagulation treatment, the symptoms disappeared. One patient refused hysterectomy and the uterine fibroids recurred 4 years after the operation. Conclusion Specific surgical plans for uterine IVL can be formulated according to cardiac ultrasound and computed tomography (CT). For the first type of tumor involving the right atrium, the right atrium tumor can be completely removed through the abdominal incision alone to avoid thoracotomy. The disease is at high risk of thrombosis and perioperative routine anticoagulation is required.

Cervical Spine Decompression and Fusion Outcomes in Trauma Patients Actively Receiving Anticoagulation Treatment for Cerebrovascular Injury: A Retrospective Comparative Study.

Cervical spine blunt trauma patients with the presence of a cerebrovascular injury may be given initiation of heparin anticoagulation treatment prior to necessary surgical stabilization. Literature regarding the safety and efficacy of these procedures while a patient is on active anticoagulation is limited, requiring further investigation. The primary research question for this study is: Can cervical spine decompression and fusion in the context of a blunt cerebrovascular injury and anticoagulation therapy be completed safely? To accomplish this a comparison of outcomes and perioperative complications was made to a control group. A total of 63 trauma patients requiring cervical spine decompression and fusion from 2013 to 2015 were identified at our North American level 1 trauma center. Evaluation of patient injury data, bleeding events, postoperative infections, and neurologic outcomes was collected from chart review. The American Spinal Injury Association (ASIA) grading system was used to measure change in postoperative neurologic outcomes. Of 63 patients, 14 had a concomitant cerebrovascular injury that required perioperative anticoagulation treatment. In the 14 patients receiving anticoagulation, 11 had anterior and 3 had posterior stabilization. A total of 2 patients experienced a complication (pneumonia and hardware failure), but neither was related to anticoagulation. An elevated prothrombin time value was noted postoperatively in 1 patient, but with no adverse outcome. No bleeding or thrombotic events, surgical site infection, or neurologic deterioration occurred. The difference in postoperative ASIA grades between groups was not significantly different (P = .57). The operative cohort receiving anticoagulation therapy did not demonstrate an increase affinity for perioperative complications or a decline in ASIA scores postoperatively when compared to a control cohort. Patients with a cerebrovascular injury receiving anticoagulation treatment can undergo safe and successful cervical spine stabilization procedures. Therapeutic level III.