Postoperative Bleeding Events Research Articles

Protamine sulfate use during tibial bypass does not appear to increase thrombotic events or affect short-term graft patency.

While the use of protamine sulfate as a heparin reversal agent has been extensively reviewed in patients undergoing carotid endarterectomy and coronary artery bypass grafting, there is a lack of literature on protamine's effects on lower extremity bypasses. The purpose of this study was to determine the risk of protamine sulfate dosing after tibial bypass on thrombotic or bleeding events, including early bypass failure. We performed a retrospective review of our institutional database for patients undergoing primary distal peripheral bypass from January 2009 through December 2015 (contralateral bypass was considered to be a new primary bypass). Primary endpoints include composite thrombotic events (myocardial infarction, stroke, amputation at 30days and patency less than 30days) and composite bleeding events (bleeding or transfusion). A total of 152 tibial or peroneal bypasses in 136 patients with critical limb ischemia were identified. Of these, 78 (57.4%) patients received protamine sulfate intraoperatively and 58 (42.6%) did not. There were no differences in composite thrombotic or hemorrhagic outcomes. Protamine use had no effect on the rates of perioperative MI (9.0% versus 3.5%, p = 0.20), stroke (1.3% versus 1.7%, p = 0.83), or perioperative mortality (5.1% versus 3.5%, p = 0.64). There was no significant difference in composite post-operative bleeding events (20.7% versus 14.1%, p = 0.31) or composite thrombotic events (17.2% versus 18.0%, p = 0.91). Patients who received protamine undergoing bypass with non-autogenous conduit had significantly higher-recorded median operative blood loss (250mL versus 150mL, p = 0.0097) and median procedure lengths (265min versus 201min, p = 0.0229). No difference in 30-day amputation-free survival was noted (91.0% versus 91.4%, p = 0.94). Follow-up Kaplan-Meier estimation did not demonstrate a difference in 30-day patency (91.7% versus 88.5%, p = 0.52). Heparin reversal with protamine sulfate after tibial or peroneal bypass grafting is not associated with higher cardiovascular morbidity, bypass thrombosis, amputation, or mortality. Additionally, there was no statistically significant difference in post-operative bleeding or thrombosis complications for patients who did not receive protamine, although the findings are suggestive of a potential difference in a more adequately powered study. Our results suggest that protamine sulfate is safe for intraoperative use without increased risk of thrombotic complications or early tibial bypass graft failure.

Marijuana use does not affect the outcomes of bariatric surgery.

The decriminalization of marijuana and legalization of derived products requires investigation of their effect on healthcare-related outcomes. Unfortunately, little data are available on the impact of marijuana use on surgical outcomes. We aimed to determine the effect of marijuana use on 30-day complications and 1-year weight loss following laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). At a large academic center, 1176 consecutive patients undergoing primary bariatric surgery from 2012 to 2017 were identified and separated into cohorts according to marijuana use. The only exclusions were 19 patients lost to follow-up. Propensity score matching, using logistic regression according to preoperative age, gender, BMI, and comorbid conditions, yielded 73 patient pairs for the control and study arms. All patients were followed two years postoperatively. Excess BMI lost did not differ between marijuana users and controls at 3weeks (23.0% vs 18.9%, p = 0.095), 3months (42.0% vs 38.1%, p = 0.416), 6months (60.6% vs 63.1%, p = 0.631), 1year (78.2% vs 77.3%, p = 0.789), or 2years (89.1% vs 74.5%, p = 0.604). No differences in the rate of major 30-day postoperative complications, including readmission, infection, thromboembolic events, bleeding events and reoperation rates, were found between groups. Follow-up rate at two years was lower in marijuana users (12.3% vs 27.4%, p = 0.023). This study suggests marijuana use has no impact on 30-day complications or weight loss following bariatric surgery, and should not be a contraindication to bariatric surgery.

Continuation of antithrombotic therapy increases minor bleeding but does not increase the risk other morbidities in open inguinal hernia repair: A propensity score-matched analysis.

An aging population has led to an increased number of patients with cardiovascular comorbidities requiring antithrombotic therapy. Perioperatively, surgeons should consider the increased risk of bleeding and thrombotic events in patients continuing or discontinuing these medications. We aimed to analyze the safety of continued antithrombotic therapy during open inguinal hernia repair. In this single-center, retrospective study, 4870 adult patients who underwent open inguinal hernia repair surgery by the same surgeon from 2008 January to 2019 March were included. Patients who underwent surgery while continuing antithrombotic therapy were included in the antithrombin group (n = 523) while those who were not under any antithrombotic therapy during the surgery were included in the control group (n = 4333). Using propensity score-matching, we then selected patients from each group with similar backgrounds. Surgery time, anesthesia time, postoperative bleeding, reoperation, and thrombotic event data were compared between the groups. Subgroup analysis based on the type of medications used was performed within the antithrombin group. Ten patients in the antithrombin group and seven patients in the control group experienced postoperative bleeding (p < 0.001). The rate of postoperative bleeding was the highest in patients taking multiple medications. However, most were managed conservatively. Three patients from the antithrombin group experienced thrombotic events postoperatively (p = 0.001). Patients receiving continued antithrombotic therapy had an increased risk of minor postoperative bleeding; however, they are a high-risk group for thrombotic events.

Dental invasive procedures in von Willebrand disease outpatients treated with high purity FVIII/VWF complex concentrate (Fanhdi®): experience of a single center

PurposeTo retrospectively assess the effectiveness and safety of customized hemostatic protocols using a plasma-derived, von Willebrand Factor (VWF)-containing Factor VIII concentrate (pdVWF/FVIII) in von Willebrand disease (VWD) patients undergoing dental invasive procedures. MethodsProtocol for each patient was drawn up by the Blood Unit based on the VWD type, disease severity, and type of treatment. pdFVIII/VWF infusions and doses were registered at 30–60 min before intervention (t0) and at 12-24-36-48-72 h after intervention (t12-t72) and up to day 7. Any peri- or postoperative bleeding, complication or adverse event was registered. ResultsForty-five dental procedures were performed on 20 VWD patients (six type-1, two type-2a, six type-2b, six type-3). Most pdFVIII/VWF infusions at t0 were 60 IU/kg (n = 7) and 50 IU/kg (n = 9). Subsequent infusions were mostly 30–50 IU/kg. No bleeding complications or adverse events were reported. ConclusionThis study supports the safety and efficacy of pdFVIII/VWF to prevent peri- and postoperative bleeding after invasive oral procedures.

Literature Review for Office-Based Anesthesia.

Literature Review for Office-Based Anesthesia.

Perioperative interruption of direct oral anticoagulants and vitamin K antagonists in patients with atrial fibrillation: A comparative analysis

BackgroundThere is a paucity of studies comparing postoperative thromboembolic and major bleeding complications following perioperative interruption of the direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs). Objective/MethodsWe conducted a retrospective cohort study to compare postoperative thromboembolic and major bleeding outcomes following perioperative interruption of DOACs and VKAs in patients with atrial fibrillation. The primary efficacy and safety outcomes were the 30‐day postoperative rates of arterial thromboembolic events (ATEs) and major bleeding, respectively. The secondary outcomes included the 30‐day rates of clinically relevant nonmajor bleeding (CRNMB) and overall mortality. Thromboembolic, major bleeding, and mortality outcomes were independently adjudicated. Multivariable mixed‐effects logistic‐regression models were used to adjust for potential confounding variables between the DOAC and VKA cohorts. ResultsA total of 325 DOAC patients undergoing 351 procedures and 199 VKA patients undergoing 221 procedures were included. The 30‐day ATE rate was 0.57% (95% confidence interval [CI], 0.27‐0.8) in the DOAC cohort. There were no ATEs in the VKA cohort. The 30‐day rates of major bleeding were 0.57% (95% CI, 0.27‐0.8) and 3.62% (95% CI, 0‐7.3) in the DOAC and the VKA cohorts, respectively. There were significantly more postoperative major bleeding events in the VKA cohort. The 30‐day rate of CRNMB was 4.27% (95% CI, 4.15‐4.42) in the DOAC cohort and 4.52% (95% CI, 3.67‐5.38) in the VKA cohort. There were 2 deaths in the VKA cohort, one of which was deemed to be a fatal nonsurgical bleeding event. ConclusionsThe perioperative interruption of VKAs may be associated with higher postoperative major bleeding rates as compared to DOACs. Careful postoperative reinitiation and monitoring of VKA anticoagulation may be warranted following surgical procedures.

A Comparison of Subperiosteal or Subgaleal Drainage with Subdural Drainage on the Outcomes of Chronic Subdural Hematoma: A Meta-Analysis

The aim of the present study was to compare the outcomes of patients with chronic subdural hematoma after undergoing burr hole craniotomy with subperiosteal or subgaleal drainage (SPGD) with those of patients who have undergone burr hole craniotomy with subdural drainage. We searched 4 databases (PubMed, Web of Science, Embase, and Cochrane Library) for relevant reports from January 1995 to September 2019. Two reviewers recorded the major outcomes data as follows: recurrence, mortality, postoperative seizures, postoperative bleeding events, surgical infection, pneumocephalus, modified Rankin scale scores, and Glasgow outcome scale scores. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. A total of 3149 patients from 10 studies were included in our analysis. Compared with the SSD group, the SPGD group had a lower recurrence rate (OR, 0.72; 95% CI, 0.57-0.91) and a smaller risk of postoperative bleeding (OR, 0.41; 95% CI, 0.22-0.78). Also, no significant differences were found in the incidence of mortality (OR, 0.79; 95% CI, 0.54-1.18), postoperative seizures (OR, 0.74; 95% CI, 0.39-1.40), surgical infection (OR, 0.98; 95% CI, 0.55-1.76), pneumocephalus (OR, 0.58; 95% CI, 0.28-1.20), modified Rankin scale score 0-3 (OR, 1.04 at discharge; OR, 1.33 at 6 months), and Glasgow outcome scale score 4-5 (OR, 1.48; 95% CI, 0.82-2.67). Burr hole craniotomy with SPGD can be recommended as an effective and safe surgical therapy for patients with chronic subdural hematoma owing to its lower recurrence rate and reduced incidence of postoperative brain injuries, in addition to no increase in the rate of some postoperative complications. However, more studies are necessary for further confirmation.

The impact of perioperative heparin bridging therapy in lung cancer surgery.

The impact of perioperative heparin bridging (HB) for lung surgery in patients on anti-clotting drugs remains unclear. We performed a retrospective study to assess its effect on surgical safety by comparing HB and non-HB groups. This study included 274 consecutive patients on anti-clotting drugs who underwent surgery for lung cancer. Of these, 77 received HB and 197 did not. Propensity score matching extracted 124 patients, consisting of 62 patients with HB and 62 patients without HB. Endpoints were surgical safety. There was no statistically significant difference in the outcomes of surgical safety outcomes between the HB and non-HB group after propensity-score matching, operative time (172 vs. 203min, p = 0.131), volume of blood loss (60 vs. 70ml, p = 0.335), need for intraoperative RBC transfusion (3.2 vs. 6.5%, p = 0.680), chest tube drainage volume on the 1st postoperative day (200 vs. 200ml, p = 0.796), and chest tube placement duration (3 vs. 3days, p = 0.606). The influence of perioperative HB on postoperative thromboembolic or bleeding events in lung cancer surgery is not obvious, but its surgical safety appears to be acceptable.

Standardized Risk Assessment and Risk-Stratified Venous Thromboembolism Prophylaxis for Patients Undergoing Breast Operation

Venous thromboembolism (VTE) prophylaxis has become routine for patients undergoing most operations, but it remains controversial for breast operations due to a perceived low risk of VTE. There is limited evidence to support routine or extended VTE prophylaxis in breast surgery. We investigated the benefits and risks of the Caprini risk stratification tool and corresponding prevention program, including extended prophylaxis for high-risk groups, in patients undergoing operations for benign and malignant breast lesions. Using Boston Medical Center data, we reviewed records of patients who underwent lumpectomy or total mastectomy (with or without axillary surgery and/or reconstruction), between 2011 and 2018, to collect information about operation, Caprini score, administration of prophylaxis, and postoperative VTE or bleeding events. Descriptive statistics were performed. Seven hundred fifty patients underwent 881 operations; 48.9% were at low or moderate risk of VTE, 43.8% were at high risk, and 7.3% were at highest risk. There were no VTE events in the low- and moderate-risk groups, 5 (1.3%) in the high-risk, and 1 (1.6%) in the highest-risk group. One patient was diagnosed with VTE during hospitalization. None of the 5 patients who developed VTE after discharge was prescribed the recommended extended chemoprophylaxis. There were 19 bleeding events that did not require reoperation; 3 patients returned to the operating room. There was no correlation of bleeding with receipt of extended chemoprophylaxis. The Caprini protocol can identify high-risk breast surgery patients who may benefit from extended VTE chemoprophylaxis, as well as low-risk patients who require no chemoprophylaxis. Furthermore, administration of extended chemoprophylaxis was not associated with an increased risk of bleeding.

Benefits may not outweigh risks of low molecular weight heparin (LMWH) in early postoperative thromboprophylaxis following minimally invasive cardiac surgery: a propensity score-matched analysis.

Whether the benefits of early prophylactic anticoagulation by low molecular weight heparin (LMWH) would outweigh its possible harms in patients after minimally invasive cardiac surgery (MICS) remains contentious. The aims of this study were to define the incidence of venous thromboembolism (VTE) and to assess whether early prophylactic anticoagulation by LMWH postoperatively was indeed effective in reducing VTE without increasing risk of complications after MICS. This investigation was a single-center, retrospective, propensity score-matched analysis study. A total of 473 patients underwent MICS, of whom 257 received prophylactic anticoagulation with LMWH (LMWH group) in the early postoperative period and 216 were not treated with LMWH (Control group). The main outcome measurements included the incidence of embolism events and major bleeding events, the volume of erythrocyte transfusion, the volume of drainage and the duration of drainage after MICS. In addition, the incidence of poor wound healing, the mechanical ventilation time, ICU stay time and postoperative hospitalization time were also documented. There were fewer embolic events (P=1.000) and a higher rate of major bleeding events (P=0.008) in the LMWH group than the Control group, and their magnitude and significance were maintained in the propensity matched analysis. In the matched cohorts, there was no significant difference in the total volume of red blood cell transfusion (P=0.552), assisted mechanical ventilation time (P=0.542), and the ICU stay time (P=0.166) between the two groups; while the volume of drainage (P<0.001) and the duration of drainage (P<0.001) in the LMWH group were significantly more than the Control group, and the incidence of poor wound healing (P=0.009) and the postoperative hospitalization time (P<0.001) were significantly increased in the LMWH group. Early prophylactic anticoagulation with LMWH could not reduce the incidence of embolism events after MICS. Instead, it might increase postoperative major bleeding events and prolong drainage tube indwelling time and the length of hospital stay.

Does Intraoperative Ketorolac Increase Bleeding in Oculoplastic Surgery?

To report adverse hemorrhagic outcomes in patients who received intravenous (IV) ketorolac during oculofacial plastic surgical procedures. The medical records of 111 consecutive patients who underwent lacrimal or orbital surgery, between the years 2016 and 2018, performed by a single surgeon under general anesthesia were retrospectively reviewed. Patients were excluded if they had history of a bleeding coagulopathy, anticoagulant use prior to surgery, or insufficient follow up. Patients were divided into 2 groups based on whether they received intravenous ketorolac. The primary outcome measure was the occurrence of a major postoperative bleeding event, and the secondary outcome measures were the evaluation of postoperative ecchymosis graded at 1 week after surgery and the incidence of persistent ecchymosis beyond 4 weeks. A total of 111 patients were analyzed further, including 31 patients who received intraoperative IV ketorolac and 80 control patients who did not. The demographic characteristics between the 2 groups were similar. No major bleeding events occurred in either group. And there was no statistically significant difference between the 2 groups in terms of ecchymosis grade and the incidence of development of persistent ecchymosis. Comparing the subgroups of lacrimal and orbital cases, there was also no significance difference between these groups. This study suggests that intraoperative ketorolac use does not increase the risk of postoperative bleeding complications in oculofacial procedures. This alternative to opioids may assist with pain control and lessen the narcotic burden.

Perioperative Bridging of Anticoagulation - Does Protocol Adherence Improve Outcomes?

Background: Perioperative warfarin management is a clinical challenge as it requires careful assessment of both thrombosis and bleeding risk associated with the planned procedure. In our experience, many clinicians favor bridging over not bridging and often use full dose unfractionated or low molecular weight heparin even when a prophylactic dose would be a reasonable alternative. To improve and standardize the complex decision-making process for anticoagulation management for patients undergoing elective surgery we introduced an evidenced-based perioperative bridging anticoagulation protocol in 2017 based on the 9th edition of American College of Chest Physicians guidelines. The aim of the study was to investigate the impact of the perioperative bridging anticoagulation protocol on postoperative bleeding and thrombotic events in patients undergoing elective surgery at our institution. We hypothesized that adherence to the proposed protocol reduces the incidence of postoperative bleeding complications without an increase in thrombotic risk. Methods: We performed a retrospective chart review for all surgical inpatients who were on long-term anticoagulation with warfarin and who required interruption of warfarin around surgery at Dartmouth-Hitchcock Medical Center from June 2016, when the protocol was introduced, to June 2019. Data were extracted from the electronic medical record for each study subject and included demographics, clinical and radiologic data, indication for long-term anticoagulation (atrial fibrillation, venous thromboembolism, or mechanical heart valve), risk categories for thrombotic events, type of surgery, anticoagulation management before and after surgery including type and dose of short-acting anticoagulation used for bridging, and bleeding and thrombotic complications within 30 days of surgery. We evaluated adherence to the bridging protocol by individual providers and divided subjects into two groups for comparison: 1) subjects who received protocol-directed care and 2) subjects who received non-protocol care. We compared the risk of postoperative bleeding and thrombotic events in the two groups using the R3.5.1. Concordance of bridge protocol and crude associations between discrete variables were assessed by McNemar's and two-tailed Fisher's exact test, respectively. Multivariate logistic regression was used to estimate covariate-adjusted association groups and the outcomes of interest. P &amp;lt; 0.05 was used as the criterion for statistical significance. Results: 194 subjects met entry criteria and were included in the study; 114 subjects were managed according to the protocol (58.8%; 95% CI = 51.5%-65.8%, McNemar's P = 0.034). Clinical characteristics were similar in the protocol-adherent and nonadherent groups. Most patients (50%) were on long-term warfarin for stroke prevention with atrial fibrillation. The incidence of bleeding and thrombotic complications for the entire population was 7.8% and 4.7 %, respectively. Two-thirds of subjects who experienced either bleeding (66.7% vs 33.3%, 95% CI= 0.91-11.93, P = 0.055, two tailed Fischer's exact test) or thrombotic (66.7% vs 33.3%, 95% CI= 0.62-19.19, P = 0.16, two tailed Fischer's exact test) complications were in the protocol-nonadherent group. Controlling for age and sex using multivariate logistic regression, subjects whose anticoagulation was not managed postoperatively in adherence to the protocol were over three times as likely to experience a bleeding complication (adjusted odds ratio=3.36, 95% CI= 1.13-11.40, P = 0.036) and a thrombotic complication (adjusted odds ratio=3.54, 95% CI=0.88-17.77, P=0.088) when compared to patients whose postoperative anticoagulation management was protocol-driven. Discussion: Overall adherence to an evidence-based anticoagulation bridging protocol by providers was only 59%. When adhered to, protocol-based practice helped to reduce bleeding complications by 60% and was associated with a trend toward a lower risk for thrombosis. Our study results emphasize the value of an evidence-based perioperative anticoagulation bridging protocol and the importance of protocol adherence. To improve adherence, we have now embedded the protocol as an order-set in our electronic medical record system and have provided additional education to providers within our institution with a plan to assess improvement in adherence subsequently. Disclosures No relevant conflicts of interest to declare.

Effect of preoperative antiplatelet or anticoagulation therapy on hemorrhagic complications in patients with traumatic brain injury undergoing craniotomy or craniectomy.

Traumatic brain injury (TBI) is common among the elderly, often treated with antiplatelet (AP) or anticoagulation (AC) therapy, creating new challenges in neurosurgery. In contrast to elective craniotomy, in which AP/AC therapy is mostly discontinued, in TBI usually no delay in treatment can be afforded. The aim of this study was to analyze the effect of AP/AC therapy on postoperative bleeding after craniotomy/craniectomy in TBI. Postoperative bleeding rates in patients treated with AP/AC therapy (blood thinner group) and in those without AP/AC therapy (control group) were retrospectively compared. Furthermore, univariate and multivariate analyses were conducted to identify risk factors for postoperative bleeding. Lastly, a proportional Cox regression analysis comparing postoperative bleeding events within 14 days in both groups was performed. Of 143 consecutive patients undergoing craniotomy/craniectomy for TBI between 2012 and 2017, 47 (32.9%) were under AP/AC treatment. No significant difference for bleeding events was observed in univariate (40.4% blood thinner group vs 36.5% control group; p = 0.71) or Cox proportional regression analysis (log rank χ2 = 0.29, p = 0.59). Patients with postoperative bleeding showed a significantly higher mortality rate (p = 0.035). In the univariate analysis, hemispheric lesion, acute subdural hematoma, hematological disease, greater extent of midline shift, and pupillary difference were significantly associated with a higher risk of postoperative bleeding. However, in the multivariate regression analysis none of these factors showed a significant association with postoperative bleeding. Patients treated with AP/AC therapy undergoing craniotomy/craniectomy due to TBI do not appear to have increased rates of postoperative bleeding. Once postoperative bleeding occurs, mortality rates rise significantly.

Postoperative Venous Thromboembolism Prophylaxis Utilizing Enoxaparin Does Not Increase Bleeding Complications After Abdominal Body Contouring Surgery

Venous thromboembolism (VTE) chemoprophylaxis warrants an individualized, risk-stratified approach, and constitutes a relatively controversial topic in plastic surgery. The aim of this study was to determine the safety of a 7-day postoperative enoxaparin regimen for VTE prophylaxis compared with a single preoperative dose of heparin in abdominal body contouring surgery. This single-institution pre-post study investigated the safety of a 7-day enoxaparin postoperative regimen in abdominal body contouring procedures performed by a single surgeon from 2007 to 2018. Four procedures were included: traditional panniculectomy, abdominoplasty, fleur-de-lis panniculectomy, and body contouring liposuction. Group I patients received a single dose of 5000 U subcutaneous heparin in the preoperative period, and no postoperative chemical prophylaxis was administered. Group II patients received 40 mg subcutaneous enoxaparin in the immediate preoperative period, then once daily for 7 days postoperatively. A total of 195 patients were included in the study, 66 in Group I and 129 in Group II. The groups demonstrated statistically similar VTE risk profiles, based on the 2005 Caprini risk-assessment model. There were no statistically significant differences in the 2 primary outcomes: postoperative bleeding and VTE events. Group I patients had higher reoperation rates (22.7% vs 10.1%, P = 0.029), which was secondary to higher rates of revision procedures. A 7-day postoperative course of once-daily enoxaparin for VTE risk reduction in abdominal body contouring surgery does not significantly increase the risk of bleeding. Implementation of this regimen for postdischarge chemoprophylaxis, when indicated following individualized risk stratification, is appropriate.

Impact of secondary interventions on mortality after fenestrated branched endovascular aortic aneurysm repair

BackgroundFenestrated and branched endovascular aortic repair (F/BEVAR) is increasingly used to manage pararenal and thoracoabdominal aortic disease (TAAA). Device-related reintervention after F/BEVAR is common, but little is known about its impact on postoperative mortality. The purpose of this analysis was to describe secondary intervention (SI) after F/BEVAR and determine the impact of these procedures on patient survival. MethodsA single-center review was done on all consecutive F/BEVARs performed from 2010 to 2016. Primary end points were incidence of secondary aortic, branch, and/or access vessel‒related SI, and survival. SI was categorized as minor endovascular (branch restenting, access vessel treatment, or percutaneous coil embolization), major endovascular (new aortic graft placement), or open (bleeding, access vessel, and/or aortic). Kaplan-Meier methodology was used to estimate freedom from SI and survival. Multivariable analysis was used to identify predictors of SI. ResultsA total of 308 F/BEVAR procedures were performed (75% physician-modified, 18% custom, 7% Zfen), with 1022 vessels revascularized (celiac, 228; superior mesenteric artery [SMA], 263; renal, 525). There were 117 (39%) extent I-III TAAA, 132 (44%) extent IV TAAA/4-vessel pararenal, and 54 (18%) <4-vessel pararenal repairs performed. Any type of SI occurred in 24% (74) of patients during the mean follow-up of 20 ± 21 months. The majority of reinterventions were endovascular (minor, 53% [n = 39]; major, 32% [n = 24]), whereas 12% (n = 9) were open and 3% (n = 2) hybrid. Primary indication for SI included: 22 (29%) with branch-related endoleaks (1C or III); 15 (22%) with proximal or distal aortic degeneration; 8 (12%) with branch vessel thrombosis/stenosis; 10 (11%) with aortic device type III endoleak/loss of overlap; 4 (6%) with postoperative mesenteric or renal bleeding events; 5 (5%) with type II endoleak; 3 (5%) with access vessel complication; and 2 (3%) with graft infection. Most SIs were elective (65%; n = 48) with the remainder occurring emergently (24%; n = 18) or for symptoms/urgently (11%; n = 8). Compared with endovascular remediation, open SI was more likely to be emergent (89%, 8 of 9; P = .001). Freedom from SI was 80 ± 3% and 64 ± 4% at 1 and 3 years, respectively. One- and 5-year survival with or without SI was: 1 year, 88 ± 4% vs 81 ± 3%; 5 years, 76 ± 5% vs 59 ± 4% (log rank test, P = .06). There was no survival difference based on type of SI (log rank test, P = .3). Extent I-III TAAA (HR, 1.6; 95% CI, 0.98-3.3; P = .06) and history of cerebrovascular disease (HR, 1.8; 95% CI, 0.97-2.6; P = .07) were predictive of SI. ConclusionsSIs after F/BEVAR most frequently involve branch vessel or aortic device remediation procedures; however, they do not negatively impact out-of-hospital survival. These results further highlight the crucial role of imaging surveillance after F/BEVAR to maintain durability. Discussions with patients, periprocedural planning, and the next generation of device design must focus on issues surrounding the risk of device-related SI events.

Periprocedural interruption of anticoagulation in patients with cancer‐associated venous thromboembolism: An analysis of thrombotic and bleeding outcomes

Unlabelled Box BackgroundPatients with cancer are at high risk for venous thromboembolic events. Venous thromboembolism (VTE) can lead to significant morbidity among patients with cancer, and is estimated to be one of the leading causes of death among cancer patients. Patients with cancer often require invasive procedures for biopsy or therapeutic purposes. There is a lack of data on postoperative outcomes following interruption of anticoagulation in this population. ObjectiveTo assess 30‐day postoperative thromboembolic and major bleeding complication rates following the perioperative interruption of anticoagulation in patients with cancer‐associated VTE. MethodsWe conducted a retrospective self‐controlled case series study with patients with cancer‐associated VTE undergoing perioperative interruption of anticoagulation at a dedicated tertiary‐care anticoagulation clinic for invasive procedures between January 2013 and March 2018. The primary efficacy and safety outcomes were the 30‐day postoperative rates of VTE and major bleeding, respectively. The secondary outcomes included the 30‐day rates of clinically relevant non‐major bleeding (CRNMB) and overall mortality. Patients undergoing multiple perioperative anticoagulation interruptions were included. ResultsOne hundred and forty‐six patients undergoing 171 periprocedural interruptions were included in our cohort. The 30‐day rates of VTE and major bleeding were both 4.1% (95% confidence interval [CI] 2.0‐8.2). The 30‐day rate of CRNMB was 2.9% (95% CI 1.3‐6.7) and the 30‐day overall mortality rate was 0.6% (95% CI 0.1‐3.4). There were no fatal postoperative VTE or major bleeding events. ConclusionsThe periprocedural interruption of anticoagulation in patients with cancer‐associated VTE is associated with high postoperative rates of VTE and major bleeding. Patients with cancer‐associated VTE may require closer follow‐up for VTE and bleeding complications after invasive procedures.

High-dose heparin is associated with higher bleeding and thrombosis rates in pediatric patients following cardiac surgery

ObjectiveTo determine the association between unfractionated heparin (UFH) dose and the rate of postoperative bleeding and thrombosis events in pediatric cardiac patients. We tested the hypothesis that high-dose UFH is associated with higher rates of bleeding and thrombosis. MethodsThis is a retrospective review of pediatric patients admitted to the cardiac intensive care unit following cardiac surgery between November 2016 and December 2017. Peripheral venous thrombosis was excluded from analysis. Bleeding was defined as spontaneous bleeding remote from procedural manipulation. Postoperative UFH dosing strategy was categorized into 3 groups: no UFH, low-dose UFH (<15 U/kg/h) and high-dose UFH (≥15 U/kg/h). Statistical analysis was performed using multivariable logistic regression. ResultsWe observed 966 consecutive patients (median age, 1.37 years; interquartile range, 0.27-5.50 years) during their stay in the cardiac intensive care unit. There were 94 patients (10%) with bleeding and 52 patients (5%) with thrombosis during follow-up. Patients receiving high-dose UFH experienced significantly more bleeding (odds ratio, 2.35; 95% confidence interval, 1.45-3.95) and thrombosis events (odds ratio, 3.65; 95% confidence interval, 1.81-7.38) compared with patients receiving low-dose UFH. The odds of bleeding (odds ratio, 0.81; 95% confidence interval, 0.45-1.47) and thrombosis (odds ratio, 0.59; 95% confidence interval, 0.26-1.35) were similar in the low-dose UFH and no-UFH groups. ConclusionsBleeding remote from immediate postsurgical bleeding occurs uncommonly in pediatric patients following cardiac surgery. Anticoagulation with high-dose UFH is associated with higher bleeding rates as well as higher thrombosis rates. Indications for high-dose UFH should be carefully considered to reduce the rate of bleeding in this population.

World workshop on oral medicine VII: Direct anticoagulant agents management for invasive oral procedures: A systematic review and meta-analysis.

This systematic review aimed to evaluate the current literature regarding the importance of discontinuing or not discontinuing direct oral anticoagulants (DOACs) before invasive oral procedures, and to establish the frequency and type of postoperative bleeding events in patients. We searched PubMed, Embase, Scopus, Web of Science, and the Cochrane Library up until November 5, 2018. Selection of the studies, extraction of data, qualitative, and bias assessment was performed independently by two authors. Twenty-one studies were included. No randomized controlled studies were identified. Six studies reported a direct comparison between patients taking DOACs and those who discontinued DOACs. The meta-analysis of these studies resulted in an OR of 0.92 (95% CI=0.37-2.27, I2 =9%) for postoperative bleeding events for patients taking DOACs. We found that 59/497 (11.8%) postoperative bleeding events occurred in patients who continued DOACs, while 27/200 (13.5%) events were reported for patients who discontinued treatment. All postoperative bleeding events were controlled with local measures. Results from the included studies did not discern any important differences in postoperative bleeding events in patients who continued versus patients who discontinued DOACs. Furthermore, no thromboembolic events were recorded. However, the low quality of the studies must be considered.

Apatinib enhances chemosensitivity of gastric cancer to paclitaxel and 5-fluorouracil.

Background and aim: Paclitaxel (PTX) plus 5-fluorouracil (5-Fu) has become the standard chemotherapy for advanced gastric cancer (GC). Apatinib, a small-molecule tyrosine kinase inhibitor targeting vascular endothelial growth factor receptor-2, improves outcomes in GC patients as a third-line treatment. However, its impact on the chemosensitivity of GC remains to be determined. Hence, we aimed to assess the efficacy and safety of apatinib combined with chemotherapy in vivo and in vitro.Methods: The MGC803 cell viability was determined by Cell Counting Kit-8 assay, and the interactions between apatinib and conventional cytotoxic agents revealed by combination index values were calculated using Calcusyn 2.0 software. We also used a zebrafish embryo xenograft model to validate the synergistic interactions. Furthermore, 4 patients with late-stage GC were enrolled to explore the efficacy and safety of PTX/Tegafur Gimeracil Oteracil Potassium (S1) (PS) chemotherapy plus apatinib in conversion surgery.Results: Apatinib showed synergistic interactions with both PTX and 5-Fu in vivo. The zebrafish embryo xenograft model also demonstrated that apatinib significantly enhanced the antitumor activity of PTX and 5-Fu. Apatinib plus PS chemotherapy was well tolerated before surgery. Objective response to preoperative SPA treatment was achieved in all 4 patients. No postoperative bleeding events or wound-healing complications were observed. No postperative morbidity occurred and no morbidity was encountered. Pathological examination showed that all patients had grade Ib pathological response.Conclusion: The experimental data suggested that apatinib improves the efficacy of PTX and 5-Fu both in vitro and in vivo. Clinical evidence showed that a combination of PS chemotherapy with apatinib may be an efficient and acceptable safety treatment for late-stage GC, especially in conversion surgery.

Abstract 31: Center-specific Variation in Use of Dual Antiplatelet Therapy Prior to Coronary Surgery: an Outcomes Analysis from the Maryland Cardiac Surgery Quality Initiative

Background: Understanding institutional practices and associated outcomes of patients managed with different dual antiplatelet therapy (DAPT) strategies prior to coronary artery bypass grafting (CABG) could inform practice improvement. We hypothesized that, while receipt of DAPT within 5 days prior to CABG would increase risk for postoperative bleeding, there is institutional variation in preoperative DAPT management. Methods: A retrospective cohort study was performed using data from the Maryland Cardiac Surgery Quality Initiative (MCSQI), a consortium aggregating data from the 10 hospitals that perform cardiac surgery in Maryland. Isolated CABG patients between 2011 and 2018 were included. The exposure variable of interest was DAPT use within 5 days prior to CABG. The temporal trend in preoperative use of DAPT, heterogeneity in DAPT usage between centers, and perioperative outcomes are reported. The primary outcomes were the STS major morbidity/mortality composite measure and postoperative bleeding events. Results: The sample included 13,965 patients, of which 23% ( n =3,219) received preoperative DAPT within 5 days of surgery. The percentage of CABG patients treated with DAPT within 5 days decreased over time from 26% in 2011 to 15% in 2018 (Figure, P &lt;0.001 for trend). There was significant heterogeneity in preoperative DAPT use among centers within the state (Figure, P &lt;0.001 for difference in proportions). CABG patients receiving preoperative DAPT were more likely to present with acute MI (49% v 27%, P &lt;0.001) and less likely to present electively (19% v 34%, P &lt;0.001). The ratio of observed-to-expected STS-defined morbidity/mortality was similar between DAPT (O/E 0.85, 95% CI 0.77-0.92) and non-DAPT groups (O/E 0.84, 95% CI 0.79-0.89). Median transfusion of blood products was higher for the DAPT group (1 [0-4] v 0 [0-3], P &lt;0.001). In adjusted models, preoperative DAPT was associated with greater odds of reoperation for bleeding (OR=1.38, P =0.017) and transfusion of ≥2 PRBC units (OR=1.27, P &lt;0.001). Conclusion: Many isolated CABG patients in the state of Maryland are treated with DAPT within 5 days prior to CABG with notable variation between centers. Given the associated risk of postoperative bleeding, standardized management of preoperative DAPT therapy could improve post-CABG outcomes.