Postoperative Anticoagulation Therapy Research Articles

Enhanced Recovery After Surgery in the Patients With Hepatocellular Carcinoma Undergoing Hemihepatectomy.

This study aims to compare the effectiveness and safety of enhanced recovery after surgery (ERAS) in patients with hepatocellular carcinoma (HCC) undergoing hemihepatectomy. From January 2017 to June 2019, 54 and 56 patients were enrolled into the control and ERAS group, retrospectively. All the indicators related to operation, liver functions, and postoperative outcomes were included in the analysis. Propensity score matching (PSM) analysis identified 72 patients for further analysis. The clinicopathological characteristics were well-matched after PSM, and there were no significant differences in the operative duration, blood loss, blood transfusion, hospital costs, and most postoperative indicators in these 2 groups. In the ERAS group, D-dimer and fibrin degradation product values were significantly reduced (3.57 (2.874.60)μg/ml vs 4.81 (3.948.29)μg/ml and 11.90 (10.0418.02)μg/ml vs 15.80 (11.5529.24)μg/ml; P = .002 and P = .023, respectively). The days that semiliquid diet was allowed after surgery (2.00 (2.003.00)days vs 5.00 (4.006.00)days, P < .001), abdominal drainage tube indwelling duration (5.00 (4.005.00)days vs 5.00 (4.756.25)days, P = .004), and hospital stay after surgery (6.00 (6.007.00)days vs 8.00 (7.0010.00)days, P < .001) were also significantly shorter. The proportion of patients requiring analgesic treatment was significantly lower in the postoperative day 2 and day 4 (P < .001 and P = .025, respectively). The morbidity was significantly less (36.11% vs 69.44%, P = .005). ERAS programs are feasible and safe in HCC patients undergoing hemihepatectomy. Postoperative anticoagulant therapy may be one of the necessary steps.

Anticoagulation Therapy After the Fontan Procedure.

The optimum postoperative anticoagulation therapy type and duration after the Fontan procedure remains unclear. This study aimed to evaluate whether our approach of administering only oral antiplatelets without warfarin due to serious bleeding complication risks in children is reasonable. We retrospectively reviewed the data of 249 patients who underwent the Fontan procedure. Total cavopulmonary connection with extracardiac conduit was performed in 230 patients (92%), the lateral tunnel Fontan procedure was performed in 18 patients (8%), and intraatrial conduit Fontan procedure was performed in one patient. Aspirin administration (initial dose: 5mg/kg/day) was continued in all patients. Only 29 patients (11%) received combined administration of aspirin and warfarin for various reasons, and warfarin was discontinued in 20 (71%) of these within a median of 16months postoperatively. Sixteen patients at high risk of thromboembolism were started on warfarin. Hospital mortality was 0%, with no thromboembolic or bleeding event-related early death. Nine late deaths, not associated with bleeding nor thromboembolism, occurred except one resulting from cardiac infarction 1.9years after the procedure. During hospitalization, five patients experienced graft thromboembolism, two of which underwent graft exchange, and the others were started on warfarin. In the late phase (3.1 ± 6.6years), cerebral infarction (n = 3), peripheral pulmonary artery occlusion (n = 2), gastrointestinal bleeding (n = 5), and respiratory hemorrhage (n = 4) occurred. Eight of nine patients with bleeding events received only aspirin. Thromboembolic events occurred in six patients within the first year after the procedure. Bleeding events occurred at 8 ± 5.5years after the procedure. Expected freedom from a thromboembolic event was 99.8% at 1year and 93.4% at 20years. Expected freedom from a bleeding event was 100% at 1year and 88.4% at 20years. In children at low risk of thromboembolism after the Fontan procedure, continuous administration of an oral antiplatelet agent alone without warfarin seems to represent a reasonable prophylactic approach.

Pharmacomechanical catheter-directed thrombolysis for acute iliofemoral deep vein thrombosis in a large study population

BackgroundWe have analyzed our single-center immediate and follow-up results in the management of acute iliofemoral deep vein thrombosis (IFDVT) using pharmacomechanical catheter-directed thrombolysis (PMCDT) to determine the safety, accuracy, and effects on quality of life and whether this treatment strategy prevents post-thrombotic syndrome (PTS). MethodsThe cases of 230 patients who had undergone PMCDT to treat IFDVT from January 2017 to December 2018 were retrospectively reviewed. The preoperative, operative, and postoperative variables, Marder scores, outcomes, and follow-up assessments with the Villalta score and venous clinical severity score were investigated. ResultsAnatomic success was achieved for 95.2% of the 230 patients. The mean Marder score had decreased from 12.65 ± 2.1 to 2.4 ± 1.3 postoperatively (P < .01). Early recurrent thrombosis had developed in 13 patients (5.65%). The primary patency at the 1-, 6-, and 12-month follow-up visits was 94.0%, 87.2%, and 81.7%, respectively. From 1 to 6 months, the Villalta score had decreased from 8.32 ± 4.14 to 3.43 ± 0.61 and the venous clinical severity score had decreased from 4.0 ± 1.8 to 1.82 ± 0.36 (P < .05). No statistically significant difference was found in the PTS severity scores at 12 months of follow-up compared with at 6 months. The mean change in the venous disease-specific quality of life from baseline to 12 months was 29.41 ± 1.99 (P = .029). The total recurrence rate was 19.63% at 1 year. ConclusionsFor a select group of patients with acute IFDVT, the use of PMCDT and postoperative anticoagulation therapy offered significant reductions in clot burden, leg pain, and swelling, achieving a significant reduction in PTS severity scores at 6 months.

A Retrospective Study of Perioperative Nursing Care of Patients After Percutaneous Left Atrial Appendage Occlusion

PurposeTo describe the retrospective audit examining nursing care of nonvalvular atrial fibrillation treated by percutaneous left atrial appendage closure (PLAAC). DesignPLAAC is a new technique for patients with atrial fibrillation unsuited for long-term oral anticoagulation treatment. The nursing care for patients treated by PLAAC has not yet been standardized. MethodsWe performed a retrospective analysis of 259 patients with nonvalvular atrial fibrillation who underwent PLAAC in our department between August 2014 and June 2018. The data included preoperative evaluations, discussions, and preparations, including psychological care and atrial thrombosis screening; postoperative observations, including electrocardiograph monitoring; prevention and care of complications; administration of postoperative anticoagulation therapy; and postoperative education, including detailed discharge guidance and regular follow-up. FindingsAll patients were discharged after 5-10 days of hospitalization. In the perioperative period, 4 cases (1.5%) developed serious complications, including 3 cases (1.2%) of delayed cardiac tamponade, cured by pericardial drainage, and 1 case of a suspected air embolism, which spontaneously recovered. During a mean follow-up period of 25.9 ± 7.9 months, all patients had good adherence to medical instructions and there were no cases of occluder displacement or shedding, thromboembolism, or severe bleeding complications. ConclusionsThe best therapeutic effect of PLAAC is strongly associated with the preoperative and postoperative training of nursing staff and the development of standard nursing procedures, including the establishment of observation and nursing manuals for complications. This study provides nursing practice information to aid in the standardization of nursing procedures for this new type of interventional therapy.

Case report: Implantation of a personal aortic corset to stabilize the size of the root and the ascending aorta in a patient with Marfan syndrome

Herein, we report a case of a patient with Marfan syndrome for whom we successfully stabilized the root and the ascending aorta to prevent further expansion and reduce the aortic rupture risk. For stabilization, a personal aortic corset was used, cut, and formed as per the individual anatomical parameters of the patient (external dimensions of the root and the ascending aorta). Using a personalized approach, we could create a stabilizing aortic framework that matched the anatomical dimensions of the root and the ascending aorta of the patient. Implantation of a personal aortic corset with borderline dimensions of the root and the ascending aorta enabled us to prevent major surgical trauma, artificial circulation, and postoperative anticoagulant therapy as well as lower the risk of further expansion and aorta rupture in our patient, who was predisposed to these events. Postoperative results 1 year later showed the absence of negative dynamics regarding an increase in the size of the root and the ascending aorta or hemodynamic disorders in the aortic valve of our patient with Marfan syndrome.Received 29 January 2021. Revised 15 March 2021. Accepted 16 March 2021.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.

Clinical update on the hybrid comprehensive stage II operation

ObjectiveWe previously described the hybrid comprehensive stage II operation as an alternate surgical procedure for a subset of patients with single ventricle congenital heart disease with adequate native ascending aortic outflow. Here we provide a clinical update on the 4 patients who have undergone this procedure. MethodsAfter undergoing a hybrid approach to the stage I Norwood palliation, the hybrid comprehensive stage II procedure was performed with an incision to the main pulmonary artery (PA), dilation of the ductal stent, creation of a stented baffle between the branch PAs, and a bidirectional Glenn connection. With this approach, dissection of the distal arch and creation of a Damus-Kaye-Stansel anastomosis was avoided. A standard Fontan procedure was planned after the usual period of growth. ResultsThe first patient, who had trisomy 21 and elevated PA pressures, died postoperatively due to left PA thrombosis. The subsequent 3 patients survived the procedure and remain clinically well. All have required catheterizations for reintervention on their stented intrapulmonary baffles and ductal arches, and all have undergone successful completion of their Fontan procedures. ConclusionsThe hybrid comprehensive stage II is a feasible, less complex alternative to the conventional comprehensive stage II operation in a subset of patients with single ventricle physiology. Early postoperative anticoagulation therapy to avoid PA thrombosis is recommended, and restenting of the ductal arch is anticipated. Although the long-term consequences of separate outflow tracts supplying the upper and lower body is unknown, the 3 surviving patients with this circulation are doing well with their Fontan circulation at midterm follow-up.

The Use of Novel Non-Vitamin K Antagonist Oral Anticoagulants Following Closure of the Left Atrial Appendage: Preliminary Results of Clinical Follow-Up.

ObjectiveThe aim of this study was to investigate the safety and efficacy of using novel non-vitamin K antagonist oral anticoagulants (NOACs) for anticoagulation following left atrial appendage closure (LAAC).MethodsA total of 70 patients with non-valvular atrial fibrillation (NVAF) were enrolled in this study. All patients underwent successful LAAC between November 2018 and September 2019 in the Department of Cardiology of the First Affiliated Hospital of the University of Science and Technology of China. All patients subsequently completed a 45-day postoperative follow-up period. Patients were grouped according to the postoperative anticoagulation regimen they received: there were 40 patients in the NOACs group and 30 patients in the warfarin group. Baseline clinical data, intraoperative data, and short-term postoperative follow-up data were collected and the two groups were compared.ResultsThe intraoperative results showed no statistical difference between the two groups in respect of the occlusion rate, the compression ratio of the occluder, the volume of pericardial effusion, or the incidence of the following: residual shunts, device-related thromboses (DRT), stroke, and pericardial effusion (P > 0.05 in all cases). The residual shunt volume in the NOACs group was significantly smaller than that in the warfarin group (P = 0.04). During the 45-day postoperative follow-up period, there was no statistical difference between the two groups in respect of the residual shunt volume, or the incidence of DRT, ischemic stroke and cerebral hemorrhage (P > 0.05 in all cases). Compared with the warfarin group, the residual shunt volume was significantly reduced in the NOACs group (P = 0.03). The incidence of minor hemorrhage and the total hemorrhage incidence in the NOACs group were significantly lower than those in the warfarin group (5% vs 30%, P = 0.004, and 5% vs 33.3%, P = 0.002, respectively).ConclusionIn this study, the use of NOACs for postoperative anticoagulation therapy following LAAC did not increase the risk of embolization or hemorrhage during the short-term follow-up period.

Release characteristics of enoxaparin sodium-loaded polymethylmethacrylate bone cement

BackgroundThis study aimed to prepare the polymethylmethacrylate (PMMA) bone cement release system with different concentrations of enoxaparin sodium (ES) and to investigate the release characteristics of ES after loading into the PMMA bone cement.MethodsIn the experimental group, 40 g Palacos®R PMMA bone cement was loaded with various amount of ES 4000, 8000, 12,000, 16,000, 20,000, and 24,000 AXaIU, respectively. The control group was not loaded with ES. Scanning electron microscopy (SEM) was used to observe the surface microstructure of the bone cement in the two groups. In the experiment group, the mold was extracted continuously with pH7.4 Tris-HCL buffer for 10 days. The extract solution was collected every day and the anti-FXa potency was measured. The experiment design and statistical analysis were conducted using a quantitative response parallel line method.ResultsUnder the SEM, it was observed that ES was filled in the pores of PMMA bone cement polymer structure and released from the pores after extraction. There was a burst effect of the release. The release amount of ES on the first day was 0.415, 0.858, 1.110, 1.564, 1.952, and 2.513, respectively, from the six groups with various ES loading amount of 4000, 8000, 12,000, 16,000, 20,000, and 24,000 AXaIU, all reaching the peak of release on the first day. The release decreased rapidly on the next day and entered the plateau phase on the fourth day.ConclusionThe prepared ES-PMMA bone cement has high application potential in orthopedic surgery. ES-PMMA bone cement shows good drug release characteristics. The released enoxaparin sodium has a local anti-coagulant effect within 24 h after application, but it will not be released for a long time, which is complementary to postoperative anti-coagulation therapy.

Efekti topikalne primene traneksamične kiseline na krvarenje u hirurgiji kolena - retrospektivna studija (topikalna primena traneksamične kiseline u hirurgiji kolena)

Introduction: Total knee arthroplasty (TKA) is a complex surgical intervention. By 2030, TKA is expected to reach as much as 3.48 million interventions yearly. Perioperative bleeding is a major problem in TKA, with intraoperative blood loss from 300 to 2000 ml. In orthopedic surgery, tranexamic acid (TXA) has been used to prevent blood loss and enable faster recovery. Here we present the first experience of topically applied tranexamic acid for TKA in our hospital. Method: The effects of topical use of TXA on bleeding for the one-year period were retrospectively analyzed. Comparisons were made between two groups: the T-TK group in which TXA was topically applied, and the 0-TK group, in which the drug was not used. Demographic data, hemoglobin and hematocrit, transfusion of allogeneic blood products, intraoperative and postoperative blood loss, anticoagulant and antiplatelet therapy, and the occurrence of postoperative complications were analyzed. Results: The study included 104 patients, 35 in the T-TK group and 69 in the 0-TK group. It was shown that patients with significantly higher intraoperative bleeding received topical TXA. Patients in the T-TK group received fewer transfusions on the first, fourth, fifth, and sixth days. Conclusion: Analysis of the initial use of topical tranexamic acid in our hospital indicates that patients with more intraoperative bleeding were those to receive the treatment. There is a need for better-defined indications for the topical use of TXA, particularly as an alternative for patients who are at higher risk of developing thromboembolic complications.

Effect of thrombophilia on clinical outcomes of chronic post-thrombotic patients after iliofemoral stenting with nitinol venous stents

ObjectiveThrombophilia is a prothrombotic condition that increases the risk of venous thromboembolism. It is unclear whether the presence of thrombophilia alters the clinical outcomes after deep venous stenting. The aim of the present study was to examine the relationship between thrombophilia and outcomes after stenting for post-thrombotic syndrome. MethodsConsecutive patients (2012-2017) receiving a nitinol venous stent for chronic post-thrombotic venous occlusive disease with a minimum of 18 months of follow-up in one center using the same anticoagulation protocol were included. The clinical history and thrombophilia testing results were reviewed. The outcomes were stent patency, which was assessed using duplex ultrasonography at 24 hours, 2 and 6 weeks, 3 months, 6 months, and annually thereafter; and reinterventions, which were performed when the stent diameter was <50% or occluded. ResultsOf the 136 patients who had undergone intervention, 55 (40%) had had a provoked deep vein thrombosis (DVT) and 81 (60%) had had an unprovoked DVT and had therefore undergone thrombophilia testing. Of the 81 patients, 38 (47%) had had either inherited (n = 19; 50%) or acquired (n = 19; 50%) thrombophilia. Of the 136 patients who had undergone stenting, 68 had required reintervention (50%) during follow-up to maintain stent patency. Of the 55 patients with a provoked DVT, 29 (53%) had required reintervention. Of the 81 patients with an unprovoked DVT, 39 (48%) had required reintervention (P = .420). Of the 38 patients with unprovoked DVT and thrombophilia, 17 (45%) had required reintervention. Of the 43 patients with unprovoked DVT and no thrombophilia, 22 (51%) had required reintervention (P = .766). The cumulative patency rate was 80% for patients with provoked DVT and 88% for those with unprovoked DVT (P = .193). The presence of thrombophilia was not associated with patency loss (92% cumulative patency for patients with thrombophilia and 84% for patients without thrombophilia; P = .307). ConclusionsUsing our anticoagulation protocol, patients with and without thrombophilia had similar clinical outcomes after deep venous stenting and should not be excluded from iliofemoral venous stenting. We found no significant differences in outcomes in conjunction with appropriate postoperative anticoagulation therapy.

Construction and validation of a nomogram for predicting the risk of portal vein thrombosis after splenectomy in patients with hepatitis B cirrhosis

To construct and validate an individualized nomogram to predict the probability of occurrence of portal vein thrombosis (PVT) after splenectomy in patients with hepatitis B cirrhosis. We retrospectively collected the clinical data from 180 patients with hepatitis B cirrhosis undergoing splenectomy with postoperative anticoagulation therapy during the period from January, 2014 to January, 2020 in our hospital. The patients were randomized into modeling group (n= 120) and validation group (n=60), and the former group was further divided into PVT group (n=49) and non-PVT group (n=71) according to the occurrence of PVT occurred within 1 month after splenectomy. The independent risk factors of PVT after splenectomy were screened in the modeling group using univariate and multivariate binary logistic regression analyses and were used for construction of the nomogram prediction model. The area under the receiver-operating characteristic (AUROC) curve (C-index), GiViTI calibration belt and Hosmer-Lemeshow test, and the DCA curve were used to estimate the discrimination power, calibration and clinical efficiency of the prediction model in both the model construction group and validation group. Univariate and multivariate logistic regression analyses showed that a history of hemorrhage, portal vein diameter, spleen vein diameter, spleen volume, varicose, postoperative platelet change, and postoperative D-dimer differed significantly between PVT group and non-PVT group (P < 0.05), and portal vein diameter, spleen vein diameter, and postoperative platelet change were independent risk factors of PVT after splenectomy (P < 0.05). The prediction model had a good discrimination power with AUROC (C-index) of 0.880 (95% CI: 0.818-0.942) in the modeling group and 0.873 (95% CI: 0.785-0.960) in the validation group. The 80% and 95%CI region of GiViTI calibration belt did not cover the 45-degree diagonal bisector line (P=0.965 and 0.632, respectively), and the P-values of the Hosmer-Lemeshow test were 0.624 and 0.911, respectively, suggesting a high reliability of the predicted probability by the model. DCA curve analysis showed a threshold probability of 30.5%, with a net benefit of 30% in the modeling group and 34% in the validation group, indicating a good clinical efficiency of the model. The model for predicting the risk of PVT after splenectomy in patients with hepatitis B cirrhosis can help in early identification of patients having high risks of PVT.

Outpatient Microsurgical Breast Reconstruction.

Background:The extensive nature of perforator-based breast reconstructions, combined with the need for postoperative flap monitoring, often leads to long hospitalizations. We present an early report demonstrating the feasibility and advantages of a modified operative technique and recovery protocol, allowing us to perform outpatient breast reconstructions with the DIEP flap. This follow-up comprises the experience gained, which is expanded to other perforator-based flaps and not limited to DIEP breast reconstructions.Methods:We have implemented a general protocol in patients undergoing breast reconstruction with autologous flaps, promoting early mobilization and discharge by improving postoperative pain and decreasing opioid requirements. This protocol includes intraoperative local anesthesia, a microfascial incision for DIEP harvest with rib preservation, along with prophylactic anticoagulation.Results:Ninety-two consecutive patients underwent autologous tissue-based breast reconstruction with DIEP, IGAP, and PAP flaps. No intraoperative complications were reported. All patients were discharged within 23 hours, without evidence of flap compromise. One patient required operative takeback for evacuation of a hematoma on postoperative day 4. No partial or total flap losses were documented. The aim of any procedure should be to get to the patient back to the preoperative status as quickly as possible, as prolonged hospitalizations are associated with higher incidences of infection, deep venous thrombosis, overall dissatisfaction, and higher overall costs of care.Conclusions:By using a modified operative technique, multimodal pain control, and postoperative anticoagulant therapy, outpatient perforator-flap–based breast reconstructions can be performed with high success and low complication rates.

Risk Factors and Clinical Significance of D-Dimer in the Development of Postoperative Venous Thrombosis in Patients with Lung Tumor.

BackgroundThe incidence of venous thromboembolism (VTE) is higher in patients with lung cancer. The aim of this study was to investigate the risk factors associated with postoperative VTE and explore the VTE predication capacity of D-dimer kinetics.Patients and MethodsSix hundred patients who had lung tumor surgery were analyzed retrospectively between January 2018 and August 2019, and venous ultrasound imaging and D-dimer examination before and after surgery were recommended to all operative patients. Of these 600 patients, 523 patients had venous thromboembolism after surgery, and 77 patients had not found. The general clinical data, postoperative prophylactic anticoagulant therapy, early systemic thromboprophylaxis, 50% increment of D-dimer, 100% increment of D-dimer, and perioperative (preoperative and days 1, 3, and 5 after surgery) D-dimer levels were collected. Logistic regression analysis was used to analyze the independent risk factors of postoperative VTE.ResultsVTE developed in 77 (12.8%) patients. In a univariate analysis, age, surgical approach, tumor size, histology, postoperative preventive anticoagulation, postoperative limb compression therapy, postoperative hemostasis, duration of operation, early systemic thromboprophylaxis, 100% increment of D-dimer, preoperative and postoperative D-dimer level, intraoperative blood loss, and time spent in the hospital were significantly different between the thrombus group and nonthrombus group (P < 0.05). Multivariate analysis showed that age >60 years (P = 0.006) and D-dimer level on 5 days after surgery (P = 0.000) were significant independent risk factors for VTE. Postoperative D-dimer was significantly higher than the preoperative level (P < 0.001). Postoperative D-dimer level was significantly different between benign and malignant tumor groups (P < 0.05) and between the thrombus group and nonthrombus group (P < 0.001). Preventive anticoagulation and limb compression therapy starting from the first day after surgery was statistically significant between the thrombus group and the nonthrombus group (P < 0.05).ConclusionContinuous detection of D-dimer level after pulmonary tumor surgery combined with thrombotic-related risk factors can better evaluate the occurrence of VTE. Preventive anticoagulant therapy and limb compression therapy starting from the first day after surgery can effectively reduce the incidence of VTE.

Anastomotic bleeding following ileocolic end-to-side anastomosis using a circular stapler: incidence and risk factors.

To identify the incidence of and risk factors for postoperative bleeding after ileocolic end-to-side anastomosis using a circular stapler. We analyzed, retrospectively, the risk factors for postoperative anastomotic bleeding in patients who underwent right-sided colectomy with end-to-side anastomosis done using a circular stapler during colon tumor surgery at our institute between January 2015 and March 2019. Anastomotic bleeding developed in 10 (3.6%) of the total 279 patients. Univariate analysis revealed that age ≥ 80years (8.8% vs. 1.9%; P = 0.008) and Eastern Cooperative Oncology Group performance status (ECOG PS) ≥ 1 (12.5% vs. 2.8%; P = 0.014) were significant risk factors for anastomotic bleeding. Postoperative anticoagulation therapy was not a risk factor for anastomotic bleeding. Multivariate analysis revealed that only age ≥ 80years was an independent risk factor (odds ratio 4.12, 95% confidence interval 1.02-16.68, P = 0.047). Six of the ten patients with anastomotic bleeding were treated conservatively, three were treated by colonoscopic clipping, and one required surgery. End-to-side anastomosis is safe and feasible, but must be performed carefully in the elderly, who are at higher risk of anastomotic bleeding.

Double-crescent sign as a predictor of chronic subdural hematoma recurrence following burr-hole surgery.

Subdural hygroma has been reported as a causative factor in the development of a chronic subdural hematoma (CSDH) following a head trauma and/or neurosurgical procedure. In some CSDH cases, the presence of a 2-layered space delineated by the same or similar density of CSF surrounded by a superficial, residual hematoma is seen on CT imaging after evacuation of the hematoma. The aims of the present study were to test the hypothesis that the double-crescent sign (DCS), a unique imaging finding described here, is associated with the postoperative recurrence of CSDH, and to investigate other factors that are related to CSDH recurrence. The authors retrospectively analyzed data from 278 consecutive patients who underwent single burr-hole surgery for CSDH between April 2012 and March 2017. The DCS was defined as a postoperative CT finding, characterized by the following 2 layers: a superficial layer demonstrating residual hematoma after evacuation of the CSDH, and a deep layer between the brain's surface and the residual hematoma, depicted as a low-density space. Correlation of the recurrence of CSDH with the DCS was evaluated by multivariate logistic regression modeling. The authors also investigated other classic predictive factors including age, sex, past history of head injury, hematoma laterality, anticoagulant and antiplatelet therapy administration, preoperative hematoma volume, postoperative residual hematoma volume, and postoperative brain reexpansion rate. A total of 277 patients (320 hemispheres) were reviewed. Fifty (18.1%) of the 277 patients experienced recurrence of CSDH within 3 months of surgery. CSDH recurred within 3 months of surgery in 32 of the 104 hemispheres with a positive DCS. Multivariate logistic analyses revealed that the presence of the DCS (OR 3.36, 95% CI 1.72-6.57, p < 0.001), large postoperative residual hematoma volume (OR 2.88, 95% CI 1.24-6.71, p = 0.014), anticoagulant therapy (OR 3.03, 95% CI 1.02-9.01, p = 0.046), and bilateral hematoma (OR 3.57, 95% CI 1.79-7.13, p < 0.001) were significant, independent predictors of CSDH recurrence. In this study, the authors report that detection of the DCS within 7 days of surgery is an independent predictive factor for CSDH recurrence. They therefore advocate that clinicians should carefully monitor patients for postoperative DCS and subsequent CSDH recurrence.

Efficacy and Safety of Short-term Postoperative Anticoagulant Therapy to Prevente Thrombosis in Arterovenous Fistula

Efficacy and Safety of Short-term Postoperative Anticoagulant Therapy to Prevente Thrombosis in Arterovenous Fistula

Cost-Effectiveness of Alternative Anticoagulation Strategies for Postoperative Management of Total Knee Arthroplasty Patients.

To evaluate the cost-effectiveness of prolonged (35-day) and standard-duration (14-day) anticoagulation therapy following total knee arthroplasty (TKA). Using Markov modeling, we assessed clinical and economic outcomes of 14-day and 35-day anticoagulation therapy following TKA with rivaroxaban, low molecular weight heparin (LMWH), fondaparinux, warfarin, and aspirin. Incidence of complications of TKA and anticoagulation therapy (deep vein thrombosis [DVT], pulmonary embolism [PE], prosthetic joint infection [PJI], and bleeding) were derived from published literature. Daily costs ranged from $1 (aspirin) to $43 (fondaparinux). Primary outcomes included quality-adjusted life years (QALYs), direct medical costs, and incremental cost-effectiveness ratios (ICERs) at 1 year post-TKA. The preferred regimen was the regimen with highest QALYs maintaining an ICER below the willingness-to-pay threshold ($100,000/QALY). We conducted probabilistic sensitivity analyses, varying complication incidence and anticoagulation efficacy, to evaluate the impact of parameter uncertainty on model results. Aspirin resulted in the highest cumulative incidence of DVT and PE, while prolonged fondaparinux led to the largest reduction in DVT incidence (15% reduction compared to no prophylaxis). Despite differential bleeding rates (ranging from 3% to 6%), all strategies had similar incidence of PJI (1% to 2%). Prolonged rivaroxaban was the least costly strategy ($3,300 at 1 year post-TKA) and the preferred regimen in the base case. In sensitivity analyses, prolonged rivaroxaban and warfarin had similar likelihoods of being cost-effective. Extending postoperative anticoagulation therapy to 35 days increases QALYs compared to standard 14-day prophylaxis. Prolonged rivaroxaban and prolonged warfarin are most likely to be cost-effective post-TKA; the costs of fondaparinux and LMWH precluded their being preferred strategies.

Two Surgical Patients with Paget-Schroetter Syndrome Presenting with Atypical Pathophysiology: Non-Effort Thrombosis.

Paget–Schroetter syndrome (PSS) is an upper extremity thrombosis occurring in the axillary and subclavian veins. PSS is also known as “effort thrombosis,” because it is usually associated with repetitive and strenuous activities of the upper limbs. We present 2 patients with atypical PSS, so-called “non-effort thrombosis,” who were not involved in vigorous activities. They underwent thoracic outlet decompression through the infraclavicular approach without concomitant venoplasty. They were discharged without postoperative anticoagulant therapy. Venography and computed tomography after surgery revealed successful recanalization of the subclavian vein in each case. We highlight the characteristic pathophysiology of “non-effort thrombosis,” an atypical PSS entity.

The strategy of zero-mortality due to postoperative VTE in patients with colorectal cancer.

511 Background: The best method of venous thromboembolism (VTE) prevention after surgery for colorectal cancer remains unclear. It is reported that about 20-40% of high-risk patients were diagnosed as DVT and 2-4% was diagnosed as PE and its mortality rate is 0.5-1.0%. The aim of this study is to evaluate the incidence of postoperative VTE patients with colorectal adenocarcinoma and to evaluate the efficacy of VTE preventive strategy. Methods: A total of 264 patients who had undergone curative surgical resection for colorectal cancer at Tokushima University Hospital were included in this study (n = 264 colon: rectum = 1:0.57). All patients were measured D-dimer preoperatively. When D-dimer was ≥ 1.1, lower extremities ultrasonography (US) was performed. All patients were treated with Heparin (10,000U/24h) continuously intravenous injection from the day of surgery, and administered Enoxaparin (2,000U/24h) subcutaneous injection after 24h of the operation. Results: In all 264 patients, 74 (28%) were D-dimer ≥ 1.1 and 16 (6%) diagnosed VTE in US (proximal:distal type n = 6:1). 239 (91%) were treated with postoperative anticoagulant therapy. 2 developed perioperative VTE (symptomatic: asymptomatic = 1:1) and after discharge 12 developed postoperative VTE and mortality rate of VTE was 0%. Univariate analysis indicated that obesity (BMI ≥ 25), hyperlipidemia and preoperative PE were risk factors for deep venous thrombosis (DVT) (p &lt; 0.0001, 0.014, 0.0135, respectively) and multivariate analysis revealed that obesity was an independent risk factor for postoperative DVT (p &lt; 0.0001). Conclusions: Obesity (BMI ≥ 25) was independent risk factor for postoperative VTE. Our preventive protocol including screening using D-dimer and lower extremities US and treatment with Enoxaparin is considered as effective for prevention of postoperative VTE.

Myocardial contrast echocardiography in the diagnosis of postoperative takotsubo myocardiopathy: case report and literature review

BackgroundTakotsubo cardiomyopathy (TCM) is a brief ventricular dysfunction that usually occurs after emotional or physical stress. Here, we report a patient who underwent cardiac surgery and then developed TCM during the postoperative period.Case presentationA 51-year-old woman was admitted to our hospital complaining of chest tightness, palpitations and dyspnoea after activity. An echocardiogram performed by our hospital showed rheumatic heart disease (severe mitral stenosis and regurgitation) with normal cardiac function and wall motion. After mitral valve replacement, this patient developed heart failure with low blood pressure and tachycardia. Urgent bedside echocardiography demonstrated akinesis in the middle and apical segments of the left ventricle and a depressed ejection fraction (EF) of 36%. Myocardial contrast echocardiography (MCE) showed similar enhancement intensity in the basal, middle and apical segments. Quantitative analysis showed approximately equivalent maximum intensity in these regions. The diagnosis was considered TCM instead of myocardial infarction. Then, an intra-aortic balloon pump was inserted to maintain effective circulation and reduce the postcardiac load. Given ventilation therapy, postoperative anticoagulation therapy and anti-infection treatment, the patient recovered quickly. In the follow-up examination, the patient remained asymptomatic and showed normalization of ventricular wall motion in the apical segment.ConclusionThis report presents a case of TCM in which MCE was used to demonstrate intact microvascular perfusion despite apical akinesis. This report might support the use of MCE as a substitute for invasive coronary angiography.