Postoperative Anticoagulation Research Articles

[Consensus on the procedure of balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension].

Chronic thromboembolic pulmonary hypertension (CTEPH) is classified as group IV pulmonary hypertension, characterized by thrombotic occlusion of the pulmonary arteries leading to vascular stenosis or obstruction, progressive increase in pulmonary vascular resistance and pulmonary arterial pressure, and eventual right heart failure. Unlike other types of pulmonary hypertension, the prognosis of CTEPH can be significantly improved by surgery, vascular intervention, and/or targeted drug therapy. Pulmonary endarterectomy (PEA) is the preferred treatment of choice for CTEPH. However, PEA is an invasive procedure with high operative risks, and is currently only performed in a few centers in China. Balloon pulmonary angioplasty (BPA) is an emerging interventional technique for CTEPH, serving as an alternative for patients who are ineligible for PEA or with residual pulmonary hypertension after PEA. BPA is gaining traction in China, but its widespread adoption is limited due to its complexity, operator skills, and equipment requirements, a lack of standard operating procedures and technical guidance, which limit the further improvement and development of BPA in China. To address this, a multidisciplinary panel of experts was convened to develop the Consensus on the Procedure of Balloon Pulmonary Angioplasty for the Chronic Thromboembolic Pulmonary Hypertension, which fomulates guidelines on BPA procedural qualification, perioperative management, procedural planning, technical approach, and complication prevention, with the aim of providing recommendations and clinical guidance for BPA treatment in CTEPH and standardizing its clinical application in this setting. Summary of recommendations: Recommendation 1: It is recommended that physicians who specialize in pulmonary vascular diseases take the lead in formulating the diagnostic and treatment plans for CTEPH, using a multidisciplinary approach.Recommendation 2: Training in BPA technique is critical; novice operators should undergo standardized operative training with at least 50 procedures under the guidance of experienced physicians before embarking on independent BPA procedures.Recommendation 3: BPA requires catheterization labs, angiography systems, standard vascular interventional devices and consumables, drugs, and emergency equipment.Recommendation 4: Patient selection for BPA should consider cardiac and pulmonary function, coagulation status, and comorbid conditions to determine indications and contraindications, thereby optimizing the timing of the procedure and improving safety.Recommendation 5: In experienced centers, patients deemed likely to benefit from early BPA, based on clinical and imaging features of CTEPH and without elevated D-dimer levels, could bypass standard 3-month anticoagulation therapy.Recommendation 6: BPA is a complex interventional treatment that requires thorough pre-operative assessment and preparation.Recommendation 7: The use of perioperative anticoagulants in BPA requires a comprehensive risk assessment of intraoperative bleeding by the operator for individualized decision making.Recommendation 8: A variety of venous access routes are available for BPA; unless contraindicated, the right femoral vein is usually preferred because of its procedural convenience and reduced radiation exposure.Recommendation 9: For the different types of vascular lesion in CTEPH, treatment of ring-like stenoses, web-like lesions, and subtotal occlusions should be prioritized before addressing complete occlusions and tortuous lesions, in order to reduce complications and improve procedural safety.Recommendation 10: A targeted, incremental balloon dilatation strategy based on vascular lesions is recommended for BPA.Recommendation 11: Intravascular pulmonary artery imaging technologies, such as OCT and IVUS can assist in accurate vessel sizing and confirmation of wire placement in the true vascular lumen. Pressure wires can be used to objectively assess the efficacy of dilatation during BPA.Recommendation 12: Endpoints for BPA treatment should be individually assessed, taking into account improvements in clinical symptoms, hemodynamics, exercise tolerance, and quality of life.Recommendation 13: Post-BPA routine monitoring of vital signs is essential; anticoagulation therapy should be initiated promptly post-procedure in the absence of complications. In cases of intraoperative hemoptysis, postoperative anticoagulation regimen adjustments should be adjusted according to the bleeding severity.Recommendation 14: If reperfusion pulmonary edema occurs during or after BPA, ensure adequate oxygenation, diuresis, and consider non-invasive positive-pressure ventilation if necessary, while severe cases may require early mechanical ventilation assistance or ECMO.Recommendation 15: In cases of intraoperative hemoptysis, temporary balloon occlusion to stop bleeding is recommended, along with protamine to neutralize heparin. Persistent bleeding may warrant the use of gelatin sponges, coil embolization, or covered stent implantation.Recommendation 16: For contrast imaging during BPA, non-ionic, low or iso-osmolar contrast agents are recommended, with hydration status determined by the patient's clinical condition, cardiac and renal function, and intraoperative contrast volume used.

Outcomes following interval delayed first rib resection for acute axillosubclavian deep venous thrombosis

BackgroundCurrent management of axillosubclavian deep venous thrombosis (DVT) often uses thrombolysis for the DVT, prompt first rib removal, and occasional venoplasty or stenting. Our institution has increasingly used anticoagulation alone followed by interval first rib resection. We sought to analyze the effectiveness of this simplified technique. MethodsBetween September 2012 and April 2021, 27 patients were identified within the institution's electronic medical record as having undergone first rib resection for upper extremity DVT. Seven of these patients had undergone preoperative thrombolysis before referral and were excluded. Among the remaining 20 patients, preoperative clinic charts were evaluated for age, venous segment involvement, contralateral limb involvement, presence of documented hypercoagulable state, duration of preoperative and postoperative anticoagulation, and postoperative outcomes. ResultsOf the 20 patients (mean age, 26.2 years; 13 males) presenting with acute axillosubclavian DVT, all patients had right (n = 8) or left (n = 12) arm swelling. Five patients had extremity pain and four had extremity discoloration. Ten had axillosubclavian vein involvement, 9 had subclavian vein involvement, and 1 had axillary vein involvement. Two patients were on oral contraceptives and no patients had any other diagnosed hypercoagulable conditions. The mean duration of preoperative and postoperative anticoagulation was 3.2 ± 2.6 months and 2.1 ± 2.1 months, respectively. Nineteen patients underwent supraclavicular first rib resection and 1 patient underwent transaxillary resection. Twelve patients (60%) demonstrated complete DVT resolution by venous duplex examination during the postoperative period and 8 patients (40%) demonstrated partial recanalization/chronic DVT. Complications included one hemothorax and one thoracic duct injury. All 20 patients remain asymptomatic without arm swelling, with a mean follow-up of 55.1 ± 34.7 months. ConclusionsAmong patients presenting with acute axillosubclavian DVT, anticoagulation alone followed by interval first rib resection proved to be successful in providing symptomatic relief in the short to medium term. By eliminating the need for preoperative thrombolysis and postoperative venograms, this potentially cost-saving algorithm simplifies our management for acute venous thoracic outlet syndrome while maintaining good clinical outcomes. Because this study only analyzed our management algorithm's effectiveness in the short to medium term, the long-term effectiveness of this treatment will need to be demonstrated.

The results of modified Konno procedure for complex left ventricular outflow tract obstruction

Background: Complex left ventricular outflow tract obstruction (c- LVOTO) necessitates an diagnosis, follow – up and operation to void severe left ventricular outflow tract obstruction. There are some procedures, for example: Aor–ventriculoplasty (the Konno-Rastan procedure), apicoaortic conduit… However, all procedures require a prosthetic or allogeneic valve as well as postoperative anticoagulation therapy, reoperation, or both, the modified Konno procedure which avoid that problems. Methods: This was a review of seri c-LVOTO  cases who underwent modified Konno procedure from 1/2014 to 12/2022. There were 8 patients ( 5 males and 3 females). The mean age was 5,6 years (range from 1 – 10 years) and the mean weight was 12,6  kilograms. The gradient of left ventricular outflow tract was 43 mmHg. All aortic valve were competents. Results:  The time of cardiopulmonary bypass, aortic clamping were: 76 mins; 56 mins. There was no mortality.  The gradient postopration of LVOT and RVOT were 14 mmHg and 8 mmHg. During follow-up time 61 months after surgery, there was no late death. The gradient  of LVOT and RVOT were 10 mmHg and 6 mmHg Conclusion: The modified Konno procedure had  good results with low gradient of  LVOT and RVOT

Postoperative bleeding after complex abdominal wall reconstruction: A post hoc analysis of a randomized clinical trial

BackgroundAbdominal wall reconstruction requires extensive dissection of the abdominal wall, exposure of the retroperitoneum, and aggressive chemoprophylaxis to reduce the risk of thromboembolic complications. The need for early anticoagulation puts patients at risk for bleeding. We aimed to quantify postoperative blood loss, incidence of transfusion and reoperation, and associated risk factors in patients undergoing complex abdominal wall reconstruction. MethodsAll patients underwent a posterior component separation with transversus abdominis release and placement of retromuscular mesh for ventral hernias <20 cm wide and were enrolled in a clinical trial assessing the utility of trans-fascial mesh fixation. A post hoc analysis was performed to quantify postoperative hemoglobin drop, blood transfusions, and procedural interventions for ongoing bleeding during the first 30 postoperative days. Multivariate logistic regression was used to identify predictors of transfusion. ResultsIn 325 patients, hemoglobin decreased by 3.61 (±1.58) g/dL postoperatively. Transfusion incidence was 9.5% (n = 31), and 3.1% (n = 10) required a surgical intervention for bleeding. Initiation of therapeutic anticoagulation postoperatively resulted in a higher likelihood of requiring surgical intervention for bleeding (odds ratio 10.4 [95% confidence interval 2.75–43.8], P < .01). Use of perioperative therapeutic anticoagulation was associated with higher rates of transfusion (odds ratio 3.51 [95% confidence interval 1.34–8.53], P < .01). Neither intraoperative blood loss nor operative times were associated with an increased transfusion requirement or need for operative intervention. ConclusionPatients undergoing transversus abdominis release are at a high risk of postoperative bleeding that can require transfusion and reoperation. Patients requiring postoperative therapeutic anticoagulation are at particularly high risk.

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

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

Anticoagulation in Patients with Premature Peripheral Artery Disease Undergoing Lower Extremity Revascularization

ObjectivesPremature peripheral artery disease (PAD), defined by lower extremity revascularization (LER) at age ≤ 50 years, is associated with poor major adverse limb events. The early onset of disease is thought to be influenced by genetic factors that regulate homeostasis of the vascular wall and coagulation. The aim of this study is to investigate the effect of anticoagulation as an adjunct to antiplatelet therapy on the outcomes of LER in patients with premature PAD. MethodsThere were 8,804 patients with premature PAD on pre- and post-operative antiplatelet therapy only and 1,236 patients on pre- and post-operative anticoagulation plus antiplatelet therapy in the Vascular Quality Initiative (VQI) peripheral vascular intervention, infra-, and suprainguinal files. Propensity score matching (2:1) was performed between patients with premature PAD who were on antiplatelet therapy and those on anticoagulation plus antiplatelet therapy. Perioperative and one-year outcomes were analyzed including reintervention, major amputation, and mortality. ResultsPatients on anticoagulation were more likely to have coronary artery disease (48.7% vs 41.2%, P<.001), congestive heart failure (20.2% vs 13.1%, P<.001), and have undergone prior LER (73.9% vs 49.2%, P<.001) compared to patients on antiplatelet therapy only. They were also less likely to be independently ambulatory (74.2% vs 81.8%, P<.001) and be on a statin medication (66.8% vs 74.3%, P<.001) compared to patients on antiplatelet therapy only. Patients on anticoagulation were also less likely to be treated for claudication (38.1% vs 48.6%, P<.001), and less likely to be treated with an endovascular procedure (64.8% vs 73.8%, P<.001). After matching for baseline characteristics, there were 1,256 patients on antiplatelet therapy only and 628 patients on anticoagulation. Patients on anticoagulation were more likely to require a return to the operating room (3.7% vs 1.6%, P<.001) and had higher perioperatively mortality (1.1% vs 0.3%, P=.032), but major amputation was not significantly different (1.8% vs 1.6%, P=.798) compared to patients on antiplatelet therapy alone. At one-year, amputation-free survival was higher in patients on antiplatelets only compared to patients on anticoagulation and antiplatelet medications (87.5% vs 80.9%, log-rank P=.001). ConclusionAnticoagulation in addition to antiplatelet therapy in patients with premature PAD undergoing lower extremity revascularization is associated with increased reintervention and mortality at one year.

Free-flap reconstruction methods in head-and-neck oncologic surgery: A CROSS practice survey of members of the French GETTEC Head-and-Neck Tumor Study Group

ObjectiveTo survey practices concerning the use of anticoagulants and antiplatelets in microvascular free-flap reconstruction following oncological surgery of the head and neck. MethodsA survey of practices was carried out between September 2022 and March 2023. An online questionnaire was sent to members of the French GETTEC Head-and-Neck Tumor Study Group in all French centers practicing head-and-neck cancer surgery with reconstruction using microvascular free-flaps. The questionnaire asked surgeons about their practices regarding the use of intra- and postoperative anticoagulants and antiplatelets, preoperative management of comorbidities, and prevention of postoperative complications. ResultsSixty-one percent of the 38 respondents (23/38) used intraoperative intravenous heparin injection, associated to flap irrigation with heparin for 76% of surgeons (29/38) and/or a heparin solution bath for 37% (14/38). Postoperative anticoagulation was used by 95% of surgeons (36/38), and antiplatelets by 40% (15/38). Postoperatively, 40% (15/38) carried out monitoring using an implantable micro-Doppler probe, associated to analysis of clinical characteristics of the flap. ConclusionReconstructive surgery using microvascular free-flaps involves numerous factors that can influence success. Prospective studies, particularly concerning the management of anticoagulants, could enable a national consensus on methods for free-flap reconstruction.

Clinical outcomes after inferior vena cava resection for malignant disease. A single center experience of 51 vena cava resections

Background and objectiveFor tumors involving inferior vena cava (IVC), surgery with complete resection remains the first line treatment. Management of IVC after resection, either ligation without reconstruction or primary reconstruction, is debated. Our study aimed to evaluate type of venous reconstruction, anticoagulation management and morbidity. MethodsA French single center database of patients who underwent partial or total circumferencial resection of the IVC for malignant disease was analyzed. Inclusion criteria were any oncologic procedure for a retroperitoneal neoplasm requiring concomitant resection of the IVC with or without venous reconstruction with prosthesis. Exclusion criteria were surgery before year 2000. Data were descriptive and reverse Kaplan Meier was used for follow-up calculation. The endpoints were the rate of prosthetic reconstruction, the use of anticoagulation and the post-operative outcomes. ResultsFifty – one patients were included with a median duration of follow-up of 54.8 months. The majority of patients were men (56.9%). Median age of the population was 44.1 years. Most of the patients underwent surgery for primary testicular cancer and for sarcoma. Complete IVC resections were performed in 46 (90,2%) patients, 32 having a concomitant prosthetic replacement. Eight patients underwent aortic resection in the same operative time. Postoperative morbidity was 33.3%. Post-operative anticoagulation was done in 24 patients. At 1 month, four patients developed thrombosis in the prosthesis. ConclusionsIVC resections are feasible and safe. Venous reconstruction and postoperative management were planned according to the preoperative imaging and intraoperative findings. We propose a decision-tree for peri-operative management and anticoagulation.

Outcomes Following Total Hip Arthroplasty in Patients Who Have Von Willebrand Disease Depend on Postoperative Anticoagulation

BackgroundVon Willebrand disease (VWD) is the most common congenital bleeding disorder. This autosomal dominant condition arises from quantitative or qualitative defects of Von Willebrand factor. To our knowledge, this study leveraged a national database to characterize the largest VWD cohort of total hip arthroplasty (THA) patients to date, assessing 90-day postoperative adverse events and 5-year revision-free survival. MethodsAdult patients who underwent primary THA for osteoarthritis were identified from January 2010 to October 2021 in a nationwide database. Patients who had and did not have VWD were matched (4:1) on age, sex, and Elixhauser Comorbidity Index and compared with multivariable logistic regression. Patients were then categorized based upon venous thromboembolism (VTE) chemoprophylaxis prescription patterns to compare bleeding and thrombotic adverse events. ResultsOf 544,851 THA patients, VWD was identified in 309 patients (0.06%). The matched cohorts contained 1,221 patients who did not have VWD and 306 patients who have VWD. On multivariable analysis, VWD patients had increased odds of 90-day VTE (odds ratio [OR] = 1.86) and hematoma (OR = 3.40) (P < .05 for all). No difference in 5-year revision-free survival was found. The VWD patients receiving aspirin or no prescriptions had greater odds of VTE (OR = 2.39, P = .048). Those on other chemoprophylaxis agents had greater odds of hematoma (OR = 4.84, P = .006). ConclusionsPatients with VWD undergoing THA had increased odds of 90-day VTE if using aspirin or no prescriptions, or hematoma if using other chemoprophylaxis. There is a delicate balancing act of clotting versus bleeding that must be considered in managing such patients, but it was reassuring that no difference in overall 5-year revision-free survival was found.

Twice-daily rivaroxaban after percutaneous left atrial appendage closure for atrial fibrillation.

Background and aim: Rivaroxaban is an emerging oral anticoagulant for postoperative anticoagulation after percutaneous left atrial appendage closure (LAAC). Because a once-daily dosing regimen of rivaroxaban causes fluctuations in the drug plasma concentration, we studied the feasibility and safety of twice-daily rivaroxaban as a postoperative anticoagulation regimen for patients with atrial fibrillation (AF) undergoing LAAC. Methods: This study involved patients with AF who underwent LAAC and took rivaroxaban postoperatively. A total of 326 patients who received a standard total dose (15 or 20mg) of rivaroxaban based on their creatinine clearance rate were divided into the twice-daily (BID) rivaroxaban group (n = 208) and once-daily (QD) rivaroxaban group (n = 118) according to their anticoagulation strategy. Transesophageal echocardiography was recommended at 3-6months postoperatively to check for device-related thrombosis (DRT). Clinical outcomes were evaluated during postoperative anticoagulation. Results: The median CHA2DS2-VASc score (4 [3, 5] vs. 4 [3, 5], p = 0.28) and HAS-BLED score (2 [2, 3] vs. 2 [2, 3], p = 0.48) were not significantly different between the groups. During the anticoagulation period (4.1 ± 0.7 vs. 4.1 ± 0.9 months, p = 0.58), 148 (71.2%) patients in the BID group and 75 (63.6%) in the QD group underwent follow-up transesophageal echocardiography. There were no statistically significant differences between the two groups in terms of DRT (1.4% vs. 2.7%, p = 0.60), minor bleeding (8.2% vs. 11.0%, p = 0.39), thromboembolic events (1.0% vs. 0.8%, p = 1.00), major bleeding (0.5% vs. 0.8%, p = 1.00), or death. Conclusion: A short course of twice-daily rivaroxaban following LAAC is a feasible alternative regimen with a low rate of major bleeding events, DRT, and thromboembolic events for patients with AF.

Utility of plasma D-dimer for diagnosis of venous thromboembolism after hepatectomy.

Venous thromboembolism (VTE) is a potentially fatal complication of hepatectomy. The use of postoperative prophylactic anticoagulation in patients who have undergone hepatectomy is controversial because of the risk of postoperative bleeding. Therefore, we hypothesized that monitoring plasma D-dimer could be useful in the early diagnosis of VTE after hepatectomy. To evaluate the utility of monitoring plasma D-dimer levels in the early diagnosis of VTE after hepatectomy. The medical records of patients who underwent hepatectomy at our institution between January 2017 and December 2020 were retrospectively analyzed. Patients were divided into two groups according to whether or not they developed VTE after hepatectomy, as diagnosed by contrast-enhanced computed tomography and/or ultrasonography of the lower extremities. Clinicopathological factors, including demographic data and perioperative D-dimer values, were compared between the two groups. Receiver operating characteristic curve analysis was performed to determine the D-dimer cutoff value. Univariate and multivariate analyses were performed using logistic regression analysis to identify significant predictors. In total, 234 patients who underwent hepatectomy were, of whom (5.6%) were diagnosed with VTE following hepatectomy. A comparison between the two groups showed significant differences in operative time (529 vs 403 min, P = 0.0274) and blood loss (530 vs 138 mL, P = 0.0067). The D-dimer levels on postoperative days (POD) 1, 3, 5, 7 were significantly higher in the VTE group than in the non-VTE group. In the multivariate analysis, intraoperative blood loss of > 275 mL [odds ratio (OR) = 5.32, 95% confidence interval (CI): 1.05-27.0, P = 0.044] and plasma D-dimer levels on POD 5 ≥ 21 μg/mL (OR = 10.1, 95%CI: 2.04-50.1, P = 0.0046) were independent risk factors for VTE after hepatectomy. Monitoring of plasma D-dimer levels after hepatectomy is useful for early diagnosis of VTE and may avoid routine prophylactic anticoagulation in the postoperative period.

Study to Evaluate the Role of Systemic Postoperative Anticoagulation Therapy in Patients Undergoing Medium-Sized Peripheral Artery Repair Following Trauma: a Randomized Controlled Trial

Study to Evaluate the Role of Systemic Postoperative Anticoagulation Therapy in Patients Undergoing Medium-Sized Peripheral Artery Repair Following Trauma: a Randomized Controlled Trial

Anticoagulation management in elderly patients with proximal femur fractures- overview of current concepts.

Proximal femur fractures (PFF) are common injuries in elderly patients and can have considerable effects on their quality of life, morbidity, and mortality. Due to pre-existing comorbidities, the prevalence of anticoagulated patients is increasing. The right timing for surgery and perioperative anticoagulation treatment remains controversial. This overview aims to summarize current practices in the pre- and postoperative anticoagulation management and the recommended time to surgery in elderly patients with PFF. Time to surgery for anticoagulated patients is often prolonged due to worries about serious perioperative bleeding and higher transfusion demands. But the delay of surgical PFF treatment increases the risk for perioperative complications like pulmonary embolism, pneumonia, deep vein thrombosis and urinary tract infections. Early surgery can be achieved with a consistent and interdisciplinary perioperative anticoagulation management. Antiplatelets do not have to be discontinued and surgery should be performed early without delay. For patients taking vitamin K antagonists (VKA) an INR less than 1.5 is recommended prior to surgery, which can be achieved by pausing VKA intake or by administering vitamin K, prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). For the treatment with direct oral anticoagulants (DOAC) a plasma drug level of under 50 pg/mL is considered safe for surgery. If the plasma level can not be determined, a gap of 24 h between the last DOAC dose and surgery is recommended. The systemic administration of tranexamic acid can reduce overall blood loss and transfusion rates in anticoagulated patients with PFF. Surgical treatment of PFF should be performed within 24 h, as delayed surgery increases the risk for perioperative complications. This also applies to anticoagulated patients, when clinically appropriate. International and interdisciplinary guidelines are necessary to ensure early and appropriate treatment of anticoagulated elderly patients with PFF.

Impact of Oral Anticoagulation on Clinical Outcomes in Postoperative Atrial Fibrillation

IntroductionThe impact of postoperative oral anticoagulation (OAC) with warfarin on postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) was the focus of this examination of patients from the randomized endo-vein graft prospective (REGROUP) Trial. Material and methodsREGROUP was a prospective randomized Veterans Affairs cooperative study comparing endoscopic versus open vein harvest in elective CABG patients (March 2014-April 2017) at 16 Veterans Affairs facilities. This study compared new-onset POAF patients who were treated with warfarin versus no-warfarin. Outcomes included stroke during active follow-up and a major adverse cardiac event composite of mortality, acute myocardial infarction, and repeat revascularization during active and passive follow-up. ResultsOf the 316/1103 (28.6%) of REGROUP patients who developed new-onset POAF, 45 patients were excluded - mainly for preoperative warfarin use. Of the remaining 269 patients, 85 received OAC with warfarin (OAC group); 184 did not (no-OAC group). Stroke rates during active follow-up (32 [IQR 24-38] mo) were 3.5% OAC group versus 5.4% no-OAC group (P = 0.76); major adverse cardiac eventrates were 20% OAC versus 11.4% no-OAC (P = 0.06). On longer follow-up of (median 4.61 [IQR 3.9-5.1] y), discharge OAC use was associated with all-cause mortality after adjusting for Society of Thoracic Surgeons mortality risk (20.0% versus 11.4% no-OAC use; HR = 2.00, 95% CI: 1.05-3.81, P = 0.035). ConclusionsREGROUP patients with POAF treated with OAC had similar stroke and higher mortality rates versus no-OAC patients. Further investigation of the risk-benefit ratio of OAC in post-CABG patients and which POAF patient subgroups might derive the most benefit with anticoagulation appears warranted.

Anticoagulation prophylaxis patterns following retroperitoneal lymph node dissection for testis cancer

IntroductionRetroperitoneal lymph node dissection (RPLND) is the standard of care for testicular cancer in various disease settings. Deep vein thrombosis (DVT) complications have been reported to occur in <1% of primary RPLND cases and up to 3% of postchemotherapy (PC-RPLND) cases. While prophylactic anticoagulation (AC) has been well-documented to reduce DVT rates in patients undergoing surgery in general, the benefit of prophylactic AC in RPLND has not been assessed. In this retrospective cohort study, we seek to address this unmet need by evaluating the rates and associated risk factors of DVT and pulmonary embolism (PE) with a national and institutional database, assess the changing patterns in DVT prophylaxis with postoperative AC following RPLND, and quantify the potential benefit of prophylactic AC in patients who have undergone RPLND using a risk-stratified approach. MethodsThe National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent RPLND during the 10-year period from 2011 to 2021. An institutional database was queried for all patients undergoing RPLND from 2013 to 2022. Patient characteristics and operative outcomes were compared between the NSQIP and the institutional database. The institutional database was stratified by prior oncologic treatment (i.e., primary RPLND vs. PC-RPLND) and outcomes were compared. Postoperative AC rate was determined and trended by year. The use of postoperative AC and PE events were stratified by clinical stage. The absolute risk reduction (ARR) of AC prophylaxis on PE events and the number needed to treat (NNT) with AC prophylaxis to prevent a single PE event was determined. ResultsIn total, the NSQIP database query resulted in 779 patients and our institutional database query resulted in 188 patients. The rate of DVT and PE was 1.2% and 0.5% vs. 2.1% and 1.6% in the NSQIP and institutional cohort, respectively. The rate of postoperative AC following RPLND in patients from the institutional database increased from 5% in 2013 to 43% in 2022 (P = 0.01). There were no statistically significant differences in complication rates, including bleeding events, chyle leaks, or hospital readmissions amongst patients who were prescribed AC at discharge and those who were not. No stage I patients developed PEs and no stage I patients were prescribed AC. The ARR for AC prophylaxis for development of PE was found to be 0.023 for the clinical stage II and stage III cohorts. The NNT to prevent a single PE with AC was 44 and 43 for the stage II and stage III cohorts, respectively. ConclusionsAC appears beneficial with minimal risk of harm after RPLND, especially in patients with higher risk of developing DVT/PE, highlighting the safety and efficacy of this regimen. There was a significant increase in the rate of AC prophylaxis at discharge amongst patients undergoing RPLND in the institutional database from 2013 to 2022. A risk-stratified protocol of postoperative AC following RPLND appears reasonable, and further prospective trials are warranted to formally confirm this recommendation.

Surgical experience in repairing the right common carotid artery and the right internal jugular vein after ECMO in neonates: early clinical results

BackgroundThe purpose of this study was to summarize the early clinical results and surgical experience of repairing the right common carotid artery and the right internal jugular vein after ECMO treatment in neonates.MethodsWe retrospectively collected the clinical data of 16 neonates with circulatory and respiratory failure who were treated with ECMO via the right common carotid artery and the right internal jugular vein in our hospital from June 2021 to December 2022. The effects of repairing the common carotid artery and internal jugular vein were evaluated.ResultsAll 16 patients successfully underwent right cervical vascular cannulation, and the ECMO cycle was successfully established. Twelve patients were successfully removed from ECMO. The right common carotid artery and the right internal jugular vein were successfully repaired in these 12 patients. There was unobstructed arterial blood flow in 9 patients, mild stenosis in 1 patient, moderate stenosis in 1 patient and obstruction in 1 patient. There was unobstructed venous blood flow in 10 patients, mild stenosis in 1 patient, and moderate stenosis in 1 patient. No thrombosis was found in the right internal jugular vein. Thrombosis was found in the right common carotid artery of one patient.ConclusionRepairing the right common carotid artery and the right internal jugular vein after ECMO treatment in neonates was feasible, and careful surgical anastomosis techniques and standardized postoperative anticoagulation management can ensure early vascular patency. However, long-term vascular patency is still being assessed in follow-up.

Abstract 16638: 4D Flow MRI Analysis of the Left Atrial Hemodynamics After Atrial Fibrillation Surgery

Introduction: Postoperative anticoagulation therapy after atrial fibrillation (AF) surgery remains a controversial topic because left atrial (LA) blood flow velocity and pattern remain unclear. This study utilizes four-dimensional (4D) flow magnetic resonance imaging (MRI) to analyze postoperative LA hemodynamics following various atrial fibrillation surgeries. Methods: This retrospective study included nine patients (mean age, 73 ± 8 years; range, 56-83 years) who underwent AF surgeries from August 2021 to June 2022. Maze surgery was performed in 3, pulmonary vein isolation (PVI) and left atrial appendage closure (LAAC) in 3, and the LAAC alone in 3 patients. Postoperative 4D flow MRI scans of the left atrium were performed, and image analysis was conducted. Blood flow velocity in the left atrium was measured, with velocities below 10 cm/s considered flow stasis. The percentage of flow stasis within one systolic-diastolic cycle was evaluated as % stasis. Furthermore, the presence or absence of a physiological vortex flow was assessed from the flow images. Results: Sinus rhythm was postoperatively maintained in 6 patients, and 3 patients were analyzed in AF. The left atrial % stasis was significantly low in the sinus rhythm group (46.0 ± 22.7 in the sinus rhythm group vs. 100 in the AF group, p=0.027). The absence of vortex flow was observed during sinus rhythm in one patient after Maze surgery. Conversely, vortex flow was identified during AF in the patient after LAAC, being accompanied by moderate mitral regurgitation. Conclusions: Any type of AF surgery does not always provide physiological LA blood flow. Further, 4D flow MRI analysis contributes to our understanding of the discrepancy between ideals and reality which may or may not require anticoagulant therapy regardless of postoperative rhythm.

Abstract 14237: Anticoagulation Strategies After Transcatheter Aortic Valve Implantation in Patients Without an Indication of Oral Anticoagulants, Network Meta Analysis of Randomized Controlled Trials

Introduction. Transcatheter aortic valve implantation (TAVI) is currently the mainstay treatment for aortic valve diseases, yet postoperative anticoagulation strategies after TAVI is still debatable. Thus, we aim to investigate the safety and efficacy of direct oral anticoagulants (DOACs) vs. single-antiplatelet therapy (SAPTs) vs. dual-antiplatelet therapy (DAPT) vs. Vitamin K antagonists (VKAs) in patients undergoing TAVI and without an indication of OACs. Methods: PubMed, Web of Science, Scopus, and Embase were systematically searched up to December 2022. A frequentist network meta-analysis has been conducted using a random-effects model calculating the odds ratio (OR) with a 95% confidence interval (CI). Results: We included 9,087 patients from 11 studies. Compared to DOACs, DAPT, SAPT, and VKAs were associated with significantly lower odds for short-term all-cause mortality (OR: 0.62; 95% CI [0.46-0.86]), (OR: 0.42; 95% CI [0.29-0.60]), (OR:0.54; 95% CI [0.31, 0.94]), respectively. DAPT was also associated with higher short-term major bleeding risk (OR:2.66; 95% CI [1.46-3.86]). Furthermore, both DAPT and SAPT were associated with significantly higher long-term bleeding rates with (OR: 1.78; 95% CI, [1.15-2.41]) and (OR:2.32; 95% CI, [1.29-3.35]), respectively. However, VKAs were associated with lower long-term bleeding rates (OR: 0.61; 95% CI, [0.24-0.98]). No intervention showed a significant difference over DOACs in terms of long-term all-cause mortality, cardiovascular mortality, and stroke, except for DAPT which showed higher odds of long-term all-cause mortality (OR: 1.83; 95% CI, [1.29-2.37]). Conclusion: Despite the long-term higher rates of major bleeding, SAPT was effective in preventing both short and long-term all-cause mortality compared to DAPT, which has both short, long term major bleeding and higher long-term all-cause mortality. Further RCTs are still required to confirm SAPT superiority compared to other strategies.

Prosthetic Conduit Use Does Not Adversely Impact Outcomes after Open Repair of Popliteal Artery Aneurysms

Single segment, greater saphenous vein (GSV) conduit is considered the optimal bypass conduit among patients undergoing bypass surgery for peripheral artery disease (PAD). While this data has been extrapolated to patients undergoing bypass for popliteal artery aneurysms (PAA), the pathophysiology of PAA is inherently different when compared to PAD, and the impact of conduit type on long-term outcomes after open repair of PAA remains unclear. A multicenter database of five regional hospitals was retrospectively reviewed for all patients with PAA undergoing open surgical repair. Data were collected on demographic information, operative details, medications, and postoperative outcomes. Kaplan-Meier curves were used to compare freedom from major adverse limb events (MALE) following GSV versus prosthetic bypass. Cox proportional hazards model was used to identify patient-level characteristics associated with MALE, which was defined as major ipsilateral limb amputation or reintervention for graft patency. From 1999-2020, a total of 101 patients with PAA underwent open exclusion and bypass surgery. Median follow-up period was 4.2 years (interquartile range, 1.3-7.4 years), and complete data were available for 99 (98.0%) patients. The majority of patients were male (99.0%) and Caucasian (93.9%). Only 11.1% of procedures were emergent, with the remainder (88.9%) being elective. All patients underwent medial exposure with a below-knee popliteal bypass target (100%). Bypass conduits included GSV (69.7%), prosthetic conduit (28.3%), and two (2.0%) alternative conduits (one spliced arm vein, one cryopreserved vein). Patients undergoing prosthetic bypass were older (72 vs 66 years, p=0.001) and had similar rates of medical comorbidities. Compared with the GSV group, patients with prosthetic conduits were more frequently placed on postoperative anticoagulation (60.7% vs 23.2%, p<0.001). Conduit type did not impact postoperative complication rates (p=NS each). MALE rates were low overall (19.2% at two years), and similar when stratified by conduit type (log rank p=0.47). On multivariable analysis, emergent bypass was associated with MALE (hazard ratio [HR] 5.73, 95% confidence interval [CI] 2.07-15.85, p<0.001). Prosthetic conduit usage (HR 1.00, 95% CI, 0.40-2.51, p=0.99) and postoperative anticoagulation (HR 1.02, 95% CI 0.42-2.50, p=0.97) were not associated with MALE. Open repair of PAA is associated with excellent long-term outcomes. Prosthetic bypass is a comparable alternative to autogenous conduit for below-knee popliteal bypass targets, and lack of suitable GSV should not prohibit open surgical repair when indicated.

Evaluation of thromboembolic prophylaxis in perioperative patients

The occurrence of thromboembolic events in the postoperative period is among the most common complications in patients admitted for surgery, especially when there is a diagnosis of malignancy. With this in mind, a number of studies have been carried out with the aim of defining the best way to prevent the occurrence of thrombosis, as well as identifying which patients would benefit most from prophylactic measures. This study consists of a narrative review of the most recent studies on prophylactic measures for thromboembolism in the respiratory setting. Objective: To define the indications for pre- and post-operative anticoagulation as prophylaxis for acute thromboembolic events. Methods: The study will be based on information collected from online databases, allowing an up-to-date perception of the best evidence on the application of anticoagulant methods in patients scheduled for surgery.