Postoperative Anticoagulation Research Articles

Recurrent, life-threatening PE in the setting of popliteal vein aneurysm in pregnancy: a case report

BackgroundPopliteal vein aneurysms (PVA) are a rare clinical entity with unknown etiology that pose a significant risk for venous thromboembolic events (VTE). The current literature supports anticoagulation and operative management. There are few case reports of PVA in pregnancy. We present a unique case of a pregnant patient with recurrent pulmonary embolism (PE) in the setting of PVA with intra-aneurysmal thrombosis who ultimately underwent surgical excision.Case presentationA previously healthy 34-year-old G2P1 at 30 weeks gestation presented to the emergency department with shortness of breath and chest pain. She was diagnosed with PE and subsequently required intensive care unit (ICU) admission and thrombolysis for a massive PE. While on a therapeutic dose of tinzaparin she had recurrence of PE in the post-partum period. She was treated with supratherapeutic tinzaparin and subsequently transitioned to warfarin. She was found to have a PVA and ultimately underwent successful PVA ligation. She remains on anticoagulation for secondary prevention of VTE.ConclusionsPVA are a rare but potentially fatal source of VTE. Patients most commonly present with symptoms of PE. The risk of VTE is elevated in the pro-thrombotic states of pregnancy and the post-partum period due to both physiologic and anatomical changes. The recommended management of PVA with PE is anticoagulation and surgical resection of the aneurysm, however this can be complicated in the setting of pregnancy. We demonstrated that pregnant patients with PVA can be temporized with medical management to avoid surgical intervention during pregnancy, but require close symptom monitoring and serial imaging to reassess the PVA, with high index of suspicion for recurrent VTE. Ultimately, patients with PVA and PE should undergo surgical resection to reduce the risk of recurrence and long-term complications. The ideal duration of post-operative anticoagulation remains unclear, and should likely be decided on based on risks, benefits, values, and shared decision making with the patient and their care provider.

Free Tissue Transfer in Sickle Cell Disease: A Case Report and Systematic Review.

Hemoglobinopathies such as sickle cell disease (SCD) are traditionally considered a relative contraindication to free tissue transfer, due to concerns that erythrocyte sickling will increase the risk of microvascular thrombosis and flap failure. This article describes a case report with the successful use of free tissue transfer in a patient with SCD and provides a systematic literature review on free tissue transfer in SCD. A retrospective chart review was performed of a patient with SCD who underwent free tissue transfer at the authors' institution. A systematic literature review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed using the keywords "free tissue transfer," "free flap," or "microsurgery" and "sickle cell" on PubMed, Ovid/Medline, and Scopus. A 29-year-old male with delayed presentation of an electrical burn to the face and scalp underwent wound closure with a free anterolateral thigh flap. Key management principles included red blood cell transfusion to keep hemoglobin S under 30% and hemoglobin greater than 10 g/dL, maintenance of hydration, normothermia, adequate analgesia, and postoperative anticoagulation. Systematic literature review identified 7 articles describing 13 cases of free tissue transfer in 10 patients with SCD, with combined complete free flap success in 10 of the 13 flaps. Free tissue transfer can be successfully performed in patients with SCD. However, evidence on the optimal management of this unique patient population in the perioperative period after free tissue transfer is limited to case reports in the literature.

Thromboembolic outcomes are decreased with the use of a standardized venous thromboembolism risk assessment and prophylaxis protocol for patients undergoing superficial venous procedures

ObjectivePatients with venous insufficiency can be treated with ablation or phlebectomy, or both. Patients undergoing superficial venous procedures have an elevated risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). At our institution, we initiated a standardized protocol in which patients with a Caprini score (2005 version) of ≥8 are treated with 1 week of prophylactic anticoagulation after the procedure. Duplex ultrasound was performed at 1 week and then within 90 days after the procedure. This aim of the present study was to determine the thrombotic and clinical outcomes after superficial vein procedures using a standardized protocol for DVT/PE risk assessment and prophylaxis. MethodsWe performed a retrospective analysis of prospectively collected data of superficial vein procedures from 2015 to 2021 at a single center. The patient demographics, CEAP (Clinical-Etiology-Anatomy-Pathophysiology) clinical class, venous clinical severity score, patient-reported outcomes, treatment type, Caprini scores, pre- and postoperative anticoagulation use, and outcomes were collected. Descriptive statistics were used for the patient demographics, procedure details, and unadjusted surgical outcomes. Multivariable logistic regression was used to evaluate the relationship between procedure type and DVT and PE after adjusting for patient characteristics, disease severity, periprocedural anticoagulation, and Caprini score. ResultsA total of 1738 limbs were treated with ablation (n = 820), phlebectomy (n = 181), or ablation and phlebectomy (n = 737). More patients were women (67.1%) and White (90.9%). The overall incidence of DVT/PE was 1.4%. Patients undergoing ablation with phlebectomy had higher rates of DVT/PE (2.7%) than those undergoing ablation (0.2%) or phlebectomy alone (1.7%; P < .01). However, only 30% of DVTs were above the knee. On multivariate analysis, only the procedure type predicted for DVT/PE. However, patients undergoing ablation and phlebectomy achieved better patient-reported outcomes (Caprini score, 5.9) compared with those undergoing ablation (Caprini score, 7.2) or phlebectomy (Caprini score, 7.9) alone (P < .01). The best improvement in the venous clinical severity score was seen with phlebectomy alone. ConclusionsThe expected difference in the DVT/PE rates between high- and low-risk groups did not materialize in our patients, perhaps secondary to the additional chemoprophylaxis prescribed for the high-risk cohort (Caprini score, ≥8). These results call for a randomized trial to assess the efficacy of a standardized protocol in the reduction of DVT/PE after superficial vein procedures.

D27. Effect of Postoperative Anticoagulation Regimen on Lower Extremity Free Flap Outcomes

PURPOSE: Free flap reconstruction for lower extremity (LE) trauma has a higher failure rate than in other anatomic regions. Anticoagulation selection in the immediate postoperative period may influence free flap outcomes. This study evaluates complication rates associated with varying anticoagulation protocols among LE free flap reconstruction. METHODS: Patients with LE trauma with free flap reconstruction from 2016-2021 were included for retrospective chart review. Complications were divided into major (hematoma, flap thrombosis, flap necrosis >10%, infection requiring reoperation) and minor (wound dehiscence, flap necrosis <10%, infection treated with antibiotic alone) categories. Patients were categorized into 4 groups based on postoperative anticoagulation regimen (aspirin, heparin drip, aspirin + heparin drip, and DVT-prophylaxis only). Complication rates were compared between each group. Univariate analysis was performed using ANOVA and chi-squared tests. Multivariable analysis was performed with a generalized linear model to predict any major complications. P values were set at P<0.05. RESULTS: Of 199 patients, 18.6% received aspirin only, 38.2% received heparin drip only, 39.2% received aspirin + heparin drip, and 4.0% received DVT prophylaxis only. Demographics were similar between the groups. Major complication rates were negatively correlated with the aspirin group (p=0.001) and the heparin drip group (p=0.031). CONCLUSION: In patients with LE free tissue transfer after acute trauma, postoperative use of aspirin only or heparin drip only results in fewer complications than aspirin + heparin drip or DVT-prophylaxis alone.

Prevention of radial artery occlusion with rivaroxaban after trans-radial access coronary procedures: The RIVARAD multicentric randomized trial.

Radial artery occlusion (RAO) remains the most frequent complication of trans-radial access. Once the radial artery is occluded, its future use as an access site for coronary procedures, or as a conduit for coronary bypass grafting or fistula for hemodialysis, will be precluded. Therefore, we aimed to assess the value of the short-term use of Rivaroxaban to prevent RAO after a trans-radial coronary procedure. This was a prospective, open-label, randomized study. The patients were randomly assigned (1:1) to one of two groups: those who received Rivaroxaban 10 mg for 7 days following the trans-radial coronary procedure (the Rivaroxaban Group) and those who received the standard treatment (the Control Group). The primary outcome was an occurrence of RAO evaluated by Doppler ultrasound at 30 days, and the secondary outcomes were hemorrhagic complications according to BARC classification. We included 521 patients randomized into two Groups: the Control Group (N = 262) and the Rivaroxaban Group (N = 259). The 1-month RAO was significantly reduced in the Rivaroxaban Group as compared to the Control Group [6.9% vs. 13%; p = 0.011, OR = 0.5, (95% CI, 0.27-0.91)]. We noted no cases of severe bleeding events (BARC3-5). The overall incidence of minor bleeding (BARC1) was 2.3%, with no significant difference between the two groups [Rivaroxaban Group = 2.7%, Control Group = 1.9%, p = 0.54, OR= 1.4, (95%CI 0.44-4.5)]. Short-term postoperative anticoagulation with Rivaroxaban 10 mg for seven days reduces the rate of 1-month RAO.

MP33-13 ANTICOAGULATION PROPHYLAXIS PATTERNS FOLLOWING RETROPERITONEAL LYMPH NODE DISSECTION: A TEN-YEAR RETROSPECTIVE ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023MP33-13 ANTICOAGULATION PROPHYLAXIS PATTERNS FOLLOWING RETROPERITONEAL LYMPH NODE DISSECTION: A TEN-YEAR RETROSPECTIVE ANALYSIS Vincent D'Andrea, Zhiyu (Jason) Qian, Kendrick Yim, Jillian Egan, Mark Preston, Graeme Steele, Matthew Mossanen, and Timothy Clinton Vincent D'AndreaVincent D'Andrea More articles by this author , Zhiyu (Jason) QianZhiyu (Jason) Qian More articles by this author , Kendrick YimKendrick Yim More articles by this author , Jillian EganJillian Egan More articles by this author , Mark PrestonMark Preston More articles by this author , Graeme SteeleGraeme Steele More articles by this author , Matthew MossanenMatthew Mossanen More articles by this author , and Timothy ClintonTimothy Clinton More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003266.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The rate of post-operative pulmonary embolism (PE) following retroperitoneal lymph node dissection (RPLND) is roughly 1%. The safety and efficacy of post-op anticoagulation (AC) prophylaxis following RPLND has been debated and there is no consensus recommendation. The aim of this study is to evaluate patterns related to the safety and efficacy of post-op AC following RPLND in the past 10 years. METHODS: Using an institutional database, patients who underwent RPLND between the dates of 2013-2022 were identified. Data including demographics, clinical stage at RPLND, post-op AC status, episodes of post-op PE, follow-up time, and testis cancer-related mortality were collected. The number needed to treat was calculated and compared for post-op AC utilization and development of PE, stratified by clinical stage. RESULTS: 188 total patients underwent RPLND for testis cancer between 2013-2022. Median age was 31. Median follow-up time was 25 months. 75% of patients were post-chemotherapy. Testis cancer-related mortality over the follow-up period was 8% (n=13).The rate of post-op AC increased from 5% in 2013 to 43% in 2022 (p=0.01) (Figure 1a). No patients discharged on AC developed a post-op PE within 6 months of discharge. There were 3 post-op PE reported within 6 months of RPLND. There was one separate DVT event which did not result in PE. Of patients diagnosed with a post-operative PE, one patient was treated with therapeutic AC, one patient required thrombectomy, and one patient died due to PE-related complications. There was one patient (not treated with post-op AC) who had a transfusion-requiring post-op bleed.There were 17 patients with Stage I, 103 patients with Stage II, and 53 patients with Stage III disease at the time of RPLND (Figure 1b). All PE events occurred in patients with clinical stage IIB or higher disease. Assuming treatment effect due to post-op AC, the number needed to treat (NNT) to prevent one PE was 54, 42, and 20 for all patients, ≥Stage II patients, and Stage III patients, respectively (Figure 1c). CONCLUSIONS: The rate of post-operative AC following RPLND has increased over the past 10 years. Retrospective analysis suggests a benefit of post-op AC, especially for patients with higher stage disease, and further prospective studies are needed to demonstrate efficacy. Source of Funding: None. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e455 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Vincent D'Andrea More articles by this author Zhiyu (Jason) Qian More articles by this author Kendrick Yim More articles by this author Jillian Egan More articles by this author Mark Preston More articles by this author Graeme Steele More articles by this author Matthew Mossanen More articles by this author Timothy Clinton More articles by this author Expand All Advertisement PDF downloadLoading ...

Verification of selective and individual pulmonary thromboembolism prophylaxes for cesarean delivery.

This study aimed to verify the utility of simple, safe, and effective venous thromboembolism (VTE) prophylaxis and implement it with few adverse events during cesarean delivery. This single-center, prospective study involved pregnant women who underwent cesarean deliveries from August 3, 2020 to March 31, 2022. Patients with VTE risk factors were initially administered unfractionated heparin (5,000 international unit [IU] subcutaneously, twice daily), 6 hours after cesarean delivery. Subsequently, they were administered enoxaparin (2,000 IU subcutaneously, twice daily). They were not administered anticoagulants if one or more of the exclusion criteria were met. The primary efficacy outcome was the incidence of symptomatic VTE. The primary safety outcome was the incidence of major bleeding. Out of the 850 women eligible for this study, 551 (64.9%) had one or more VTE risk factors and 299 (35.1%) had no risk factors. Of the 551 women with one or more VTE risk factors, 15 met one or more exclusion criteria for enoxaparin administration. A total of 314 women received only perioperative mechanical prophylaxis, including 15 who met the exclusion criteria for anticoagulants and 299 without VTE risk factors. During implementation of the protocol, no woman developed symptomatic VTE after cesarean delivery. Major bleeding occurred in only one woman who received postoperative anticoagulants. This protocol, which clarified the administration of anticoagulants according to VTE risk factors and dose reduction/discontinuation criteria, may be an effective and safe VTE prophylaxis for cesarean deliveries.

Immediate postoperative parenteral anticoagulant therapy in patients with mesenteric ischemia after intestinal resection: a retrospective cohort study at a single institute

BackgroundBowel gangrene represents a major fatal event in acute mesenteric ischemia. Intestinal resection is inevitable in patients with peritonitis and bowel gangrene. This retrospective study aimed to elucidate the benefit of postoperative parenteral anticoagulation in patients with intestinal resection.MethodsPatients with acute mesenteric ischemia and bowel gangrene were recruited retrospectively between January 2007 and December 2019. All patients underwent bowel resection. They were categorized into two groups: patients without immediate parenteral anticoagulant therapy (Group A) and those with immediate parenteral anticoagulant therapy (Group B). Thirty-day mortality and survival were analyzed.ResultsA total of 85 patients were included, with 29 patients in Group A and 56 patients in Group B. Patients in Group B had lower 30-day mortality (16.1%) and a higher 2-year survival rate (45.4%) than patients in Group A (30-day mortality: 51.7%, p = 0.001; 2-year survival rate: 19.0%, p = 0.001). In the 30-day mortality multivariate analysis, patients in Group B had a better outcome (odds ratio = 0.080, 95% confidence interval between 0.011 and 0.605, p = 0.014). Patients in Group B also had a better outcome in the survival multivariate analysis (hazard ratio: 0.435, 95% confidence interval between 0.213 and 0.887, p = 0.022).ConclusionsImmediate postoperative parenteral anticoagulant therapy improves prognosis in patients with acute mesenteric ischemia treated by intestinal resection.Trial registration This research was retrospectively approved by the Institutional Review Board (IRB) I&II of Taichung Veterans General Hospital (TCVGH-IRB No.CE21256B) on July 28th, 2021. The informed consent waiver was also approved by IRB I&II of Taichung Veterans General Hospital. The Declaration of Helsinki and ICH-GCP guidelines were followed during this study.

Effect of Perioperative Antithrombotics on Head and Neck Microvascular Free Flap Survival After Anastomotic Revision.

To determine if antithrombotic therapy improves head and neck microvascular free flap survival following anastomotic revision. A retrospective review of all patients with microvascular free tissue transfer to the head and neck between August 2013 and July 2021. Otolaryngology-Head and Neck Surgery Departments at University of Alabama at Birmingham, University of Colorado, and University of California Irvine. Perioperative use of anticoagulation, antiplatelets, intraoperative heparin bolus, tissue plasminogen activator (tPA) and vasopressor use, and leech therapy were collected plus microvascular free flap outcomes. The primary endpoint was free flap failure. Analyses of free flaps that underwent anastomotic revision with or without thrombectomy were performed. A total of 843 microvascular free flaps were included. The overall rate of flap failure was 4.0% (n = 34). The overall rate of pedicle anastomosis revision (artery, vein, or both) was 5.0% (n = 42) with a failure rate of 47.6% (n = 20) after revision. Anastomotic revision significantly increased the risk of flap failure (odds ratio [OR] 52.68, 95% confidence interval [CI] [23.90, 121.1], p < .0001) especially when both the artery and vein were revised (OR 9.425, 95% CI [2.117, 52.33], p = .005). Free flap failure after the anastomotic revision was not affected by postoperative antiplatelet therapy, postoperative prophylactic anticoagulation, intraoperative heparin bolus, tPA, and therapeutic anticoagulation regardless of which vessels were revised and if a thrombus was identified. In cases of microvascular free tissue transfer pedicle anastomotic revision, the use of antithrombotic therapy does not appear to significantly change free flap survival outcomes.

Stanford Type A Aortic Dissection in A Patient with Primary Antiphospholipid Syndrome and Coronavirus Disease 2019

Acute aortic dissection is one of the most lethal diseases, affecting the lining of the aortic wall. We describe a case of Stanford Type A aortic dissection in a patient with underlying primary antiphospholipid syndrome (APS) complicated by coronavirus disease 2019 (COVID-19). APS is characterized by recurrent venous and/or arterial thrombosis, thrombocytopenia, and rarely vascular aneurysms. The hypercoagulable milieu attributable to APS and the prothrombotic state from COVID-19 posed a challenge in achieving optimal postoperative anticoagulation in our patient.

Features and risk factors of early intraluminal thrombus formation within the frozen elephant trunk stent graft

ObjectiveThe frozen elephant trunk is a standard treatment method for aortic arch pathologies extending into the descending aorta. We previously described the phenomenon of early postoperative intraluminal thrombosis within the frozen elephant trunk. We investigated the features and predictors of intraluminal thrombosis. MethodsA total of 281 patients (66% male, mean age 60 ± 12 years) underwent frozen elephant trunk implantation between May 2010 and November 2019. In 268 patients (95%), early postoperative computed tomography angiography was available to assess intraluminal thrombosis. ResultsThe incidence of intraluminal thrombosis after frozen elephant trunk implantation was 8.2%. Intraluminal thrombosis was diagnosed early after the procedure (4.6 ± 2.9 days) and could be successfully treated with anticoagulation in 55% of patients. A total of 27% developed embolic complications. Mortality (27% vs 11%, P = .044) and morbidity were significantly higher in patients with intraluminal thrombosis. Our data showed a significant association of intraluminal thrombosis with prothrombotic medical conditions and anatomic slow flow features. The incidence of heparin-induced thrombopenia was higher in patients with intraluminal thrombosis (18% vs 3.3%, P = .011). Stent-graft diameter index, anticipated endoleak Ib, and degenerative aneurysm were significant independent predictors of intraluminal thrombosis. Therapeutic anticoagulation was a protective factor. Glomerular filtration rate, extracorporeal circulation time, postoperative rethoracotomy, and intraluminal thrombosis (odds ratio, 3.19, P = .047) were independent predictors of perioperative mortality. ConclusionsIntraluminal thrombosis is an underrecognized complication after frozen elephant trunk implantation. In patients with risk factors of intraluminal thrombosis indication for frozen elephant trunk should be carefully evaluated and postoperative anticoagulation considered. Early thoracic endovascular aortic repair extension should be considered in patients with intraluminal thrombosis to prevent embolic complications. Stent-graft designs should be improved to prevent intraluminal thrombosis after frozen elephant trunk implantation.

Bioprosthetic valve monitoring in patients with carcinoid heart disease.

Carcinoid heart disease (CnHD) is a frequent cause of morbidity and mortality in patients with neuroendocrine tumors and carcinoid syndrome. Although valve replacement surgery appears to decrease all-cause mortality in patients with advanced CnHD, few studies have investigated the outcomes of patients after valve replacement. We conducted a multi-institution retrospective registry of patients who received both tricuspid and pulmonic bioprosthetic valve (TV/PV) replacements for advanced CnHD from November 2005 to March 2021. Patients were followed post-operatively with echocardiographic studies every 3 months. Carcinoid valvular heart disease scores were used to monitor valve degeneration. Neuroendocrine tumor treatment, their administration times, and associations with echocardiographic findings were recorded. Of 87 patients with CnHD, 22 patients underwent simultaneous surgical TV and PV replacement. In 6 patients (27.3%), increased PV Vmax was the first echocardiographic manifestation of valve degeneration in the setting of occult neurohormonal release. Post-operative telotristat ethyl and peptide receptor radionuclide therapy appeared to stabilize PV Vmax. The PV Vmax showed consistent elevation in the entire patient population when compared to baseline, while bioprosthetic TV echocardiographic parameters were relatively unchanged throughout. Post-operative warfarin therapy did not affect the rate of PV degeneration, and no major bleeding was recorded during or after post-operative anticoagulation therapy. Bioprosthetic valve degeneration is common in CnHD. Monitoring with echocardiographic studies every 3 months, focusing on PV velocities, could identify patients with occult disease that very likely promotes valve degeneration. Novel neuroendocrine tumor therapies may have a beneficial impact on valve degeneration.

Hormone replacement therapy does not increase thrombosis risk following THA: a national database study

PurposeHormone replacement therapy (HRT) causes a significant increase in the risk of venous thrombosis. The risk of medical and surgery-related complications among women taking HRT following total hip arthroplasty (THA) is poorly understood, and there are currently no guidelines in place regarding venous thromboembolism prophylaxis in this patient population. The purpose of this study was to evaluate the frequency of early medical and surgery-related complications following THA among women taking HRT.MethodsWomen aged > 40 years of age who underwent primary THA were identified from a retrospective database review. A control group of non-HRT users was matched using propensity scoring to HRT users. Rates of 90-day medical complications and 1-year surgery-related complications were compared between cohorts using odds ratios. Postoperative anticoagulation regimens were also compared.ResultsThere were 3,936 patients in the HRT cohort who were matched to 39,360 patients not taking HRT. There were no significant differences in rates of DVT (OR 0.94, p = 0.6601) or PE (OR 0.80, p = 0.4102) between cohorts. Patients on HRT were more likely to sustain a dislocation (OR 1.35, p = 0.0269) or undergo revision surgery (OR 1.23, p = 0.0105). HRT patients were more likely to be prescribed warfarin (OR 1.21, p = 0.0001) or enoxaparin (OR 1.18, p = 0.0022) and less likely to be prescribed rivaroxaban (OR 0.62, p < 0.0001) compared to controls.ConclusionsHRT was not found to be an independent risk factor for thromboembolism following THA. Further research is warranted to better delineate the ideal perioperative medical management of HRT users undergoing THA.

Upregulation of Coagulation Factor VIII and Fibrinogen After Pulmonary Endarterectomy in Patients with Chronic Thromboembolic Pulmonary Hypertension.

Chronic thromboembolic pulmonary hypertension (CTEPH) is associated with thrombotic states including elevated coagulation factor VIII (FVIII). Pulmonary endarterectomy (PEA) is the main treatment for CTEPH, and efficient anticoagulation is essential to prevent thromboembolism recurrence after surgery. We aimed to characterize longitudinal changes in FVIII and other coagulation biomarkers after PEA. Coagulation biomarker levels were measured at baseline and up to 12 months after operation in 17 consecutive patients with PEA. Temporal patterns of coagulation biomarkers, and correlation of FVIII with other coagulation biomarkers, were analyzed. Baseline FVIII levels were elevated in 71% of the patients (mean 216 ± 67 IU/dl). FVIII doubled 7 days after PEA, peaking at 471 ± 87 IU/dl, and gradually returned to respective baseline levels within 3 months. Postoperative fibrinogen levels were also elevated. Antithrombin decreased at 1 to 3 days, D-dimer increased at 1 to 4 weeks, and thrombocytosis was observed at 2 weeks. FVIII is elevated in most patients with CTEPH. After PEA, early but transient elevation of FVIII and fibrinogen, and delayed reactive thrombocytosis, occurs, and warrants careful postoperative anticoagulation to prevent thromboembolism recurrence.

Free Jejunal Graft Interposition with Vascular Reconstruction in Patients Undergoing Pharyngo Laryngo Esophagectomy

Pharyngo-esophageal reconstruction using free jejunal grafts has been widely used for the treatment of locally advanced carcinomas of the hypopharynx and cervical esophagus. However, the procedure is technically demanding and requires complex recontractions. The aim of this study was to evaluate our institutional outcomes of reconstruction using a free jejunal graft with vascular reconstruction in patients undergoing pharyngo laryngo esophagectomy with a multidisciplinary surgical team. There were 90 consecutive patients between October 2006 and February 2021. The mean age was 64.6±10.3years, and there were 76 male patients. Of 90 patients, 49 underwent preoperative chemotherapy and/or radiotherapy. Jejunal vessels were commonly anastomosed to the common carotid artery and the internal jugular vein (77.8% and 92.2%, respectively). Continuous intravenous infusion of heparin was used postoperatively. Necrosis of the graft was observed in 5 patients. An isolated revision of vein was necessary in 1 patient. In all cases of graft failure, heparin was not used postoperatively. On the other hand, among the patients without graft failure, heparin was used for about two-thirds of the patients and was significantly different (0% vs. 66%, P=0.01). Free jejunal graft with vessel reconstruction is a safe and effective method for patients undergoing pharyngo laryngo esophagectomy. The position for the prevention of kinking as well anastomosis maneuver of vein is especially important. Moreover, early postoperative anticoagulation is essential.

Anticoagulation for Patients Undergoing Implantation of a Cardiac Implantable Electronic Device.

The number of cardiac devices implanted increases year on year, as does the complexity of the patients being managed. A large proportion of this patient group have an indication for anticoagulation, and this raises challenges around the perioperative management of these agents. A quality improvement project was conducted to review current practice, understand local experience and improve patient care. Following the initial review, local guidelines were updated, the postoperative anticoagulation decision escalated to the responsible clinician and a clearer pathway for communicating the decision created. The implemented changes have shown an overall improvement in junior doctor feedback and also clinical documentation in the electronic patient records.

Cryopreserved platelets compared with liquid-stored platelets for the treatment of surgical bleeding: protocol for two multicentre randomised controlled blinded non-inferiority trials (the CLIP-II and CLIPNZ-II trials)

IntroductionCryopreservation at −80°C in dimethylsulphoxide extends platelet shelf-life from 7 days to 2 years. Only limited comparative trial data supports the safety and effectiveness of cryopreserved platelets as a treatment...

Comparison of Activated Clotting Time to Hepcon Protamine Titration for Anticoagulation Management during Cardiopulmonary Bypass Surgery in a Patient with Severe Hemophilia a on Emicizumab Prophylaxis

Background: Emicizumab is a bispecific monoclonal antibody that bridges factor IXa and X, substituting the cofactor function of FVIII, but artificially shortens aPTT and interferes with aPTT-based assays. The activated whole blood clotting time (ACT) is the preferred point-of-care test to monitor anticoagulation with high-dose heparin in cardiopulmonary bypass (CPB). While theoretically ACT may be susceptible to the effects of emicizumab as the intrinsic pathway is involved, in vitro human clinical data suggest that emicizumab does not interfere with the ACT. There has been little experience managing patients with hemophilia A on emicizumab during CPB, and in most cases it is not feasible to delay surgery to await clearance of emicizumab due its long half-life. Heparin concentration by Hepcon protamine titration is an alternative monitoring method. Case: We describe the perioperative management of a patient with severe hemophilia A on maintenance emicizumab prophylaxis who underwent CPB with high-dose heparin monitored with both ACT and Hepcon. This 54-year-old male has a complex medical profile including Child Pugh B cirrhosis (baseline INR 1.5, platelets 100), Hepatitis C (treated), HIV on antiretroviral therapy (undetectable viral load), and remote portal vein thrombosis in the context of FEIBA and tranexamic acid use for a gastrointestinal bleed. He was diagnosed with Group B Streptococcus infective endocarditis. Despite optimal medical management, he developed aortic root abscess and aortic regurgitation necessitating operative intervention. A multidisciplinary team of hematology, cardiology, and cardiac surgery/anesthesia/intensive care deemed the risk of bleeding significant but not prohibitive and created a perioperative plan with liberal FVIII replacement followed by chromogenic FVIII levels postop (Table 1) to guide dosing. A bioprosthetic valve was chosen to reduce the need for postoperative anticoagulation. Emicizumab prophylaxis was continued. Intra-operative heparin titration was performed by the Hepcon point-of-care assay, but concurrent ACT measurements were taken to investigate the effect of emicizumab. INR, fibrinogen, hemoglobin, and platelet levels were measured as per surgical protocol. Preop FVIII replacement with moroctocog alfa (Xyntha®) (60 U/kg) was administered to target a ~120% FVIII level. Tranexamic acid was administered intraoperatively as per surgical protocol. He underwent a successful aortic valve replacement, bovine patch reconstruction and aortic root repair on CPB pump for a total of 175 minutes with no excessive intraoperative bleeding. Table 1 summarises the perioperative course, point-of-care testing results, hemostatic therapy, and FVIII levels. Following administration of protamine at the end of CPB (ACT 135s, Hepcon 0 U/mL) there was persistent oozing from the sternum which lessened with surgical packing and additional Xyntha®, but ultimately the chest was closed in favour of medical management. Two hours post-op there was ~1600mL of blood loss via chest tubes despite a FVIII level of 89%, platelets 147, and INR 1.7. Fibrinogen concentrate, fresh frozen plasma, and platelets were given prior to a repeat OR for exploration. Bleeding was confirmed from the sternal bone and muscle, and hemostasis was achieved with cautery and sutures. The remainder of the post-op course was uneventful with no further bleeding on emicizumab prophylaxis and FVIII replacement for 14 days. Discussion: The ACT and Hepcon results followed a similar trajectory over the operative course (Fig 1). Baseline and post-protamine ACT results were above normal reference range for non-anticoagulated patients (90-120s), and the intraoperative values were consistently above the target of 480s for CPB even when the Hepcon results fell below target (4.1 U/mL). The ACT results weren't artificially lowered with emicizumab, in fact elevated ACT values could have led to heparin underdosing risking circuit thrombosis. ACT is influenced by multiple variables including platelet count and function, antiphospholipids, factor deficiencies, temperature, and hemodilution. Therefore, the results may reflect derangements in one or more of these variables. We need further preclinical and clinical studies to better characterize the effect of emicizumab on ACT and identify the safest intraoperative monitoring strategy for patients on emicizumab requiring CPB surgery. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Anticoagulant Usage After Anterior Cruciate Ligament Reconstruction Is Associated With Increased Rate of Manipulation Under Anesthesia.

Arthrofibrosis after anterior cruciate ligament reconstruction (ACLR) is a notable but uncommon complication of ACLR. To improve range of motion after ACLR, aggressive physical therapy, arthroscopic/open lysis of adhesions, and revision surgery are currently used. Manipulation under anesthesia (MUA) is also a reasonable choice for an appropriate subset of patients with inadequate range of motion after ACLR. Recently, the correlation between anticoagulant usage and arthrofibrosis after total knee arthroplasty has become an area of interest. The purpose of this study was to determine whether anticoagulant use has a similar effect on the incidence of MUA after ACLR. The Mariner data set of the PearlDiver database was used to conduct this retrospective cohort study. Patients with an isolated ACLR were identified by using Current Procedural Terminology codes. Patients were then stratified by MUA within 2 years of ACLR, and the use of postoperative anticoagulation was identified. In addition, patient demographics, medical comorbidities, and timing of ACLR were recorded. Univariate and multivariable analyses were used to model independent risk factors for MUA. We identified 216,147 patients who underwent isolated ACLR. Of these patients, 3,494 (1.62%) underwent MUA within 2 years. Patients who were on anticoagulants after ACLR were more likely to require an MUA (odds ratio [OR]: 2.181; P < 0.001), specifically low-molecular-weight heparin (OR: 2.651; P < 0.001), warfarin (OR: 1.529; P < 0.001), and direct factor Xa inhibitors (OR: 1.957; P < 0.001). In conclusion, arthrofibrosis after ACLR is associated with the use of preoperative or postoperative thromboprophylaxis. Healthcare providers should be aware of increased stiffness among these patients and treat them aggressively.

7893 Venous Thromboembolism Prophylaxis after Hysterectomy for Endometrial Malignancy in Class III Obesity: Patient Preferences and Outcomes

<h3>Study Objective</h3> This study assessed patient preference between two anticoagulants for postoperative venous thromboembolism (VTE) prophylaxis following hysterectomy for endometrial intraepithelial neoplasia (EIN) or grade 1 endometrioid adenocarcinoma in patients with class III obesity. <h3>Design</h3> Prospective quality improvement study. <h3>Setting</h3> Canadian urban, tertiary-care hospital. <h3>Patients or Participants</h3> All patients undergoing hysterectomy for EIN or grade 1 endometrial cancer with a body mass index (BMI) ≥ 40 between February 2021 and March 2022 who were eligible for extended postoperative anticoagulation, which is recommended in this population due to the high risk of VTE. <h3>Interventions</h3> Patients were provided with information about dalteparin, an injectable low-molecular weight heparin, and apixaban, a direct oral anticoagulant, prior to surgery. Postoperatively, patients were surveyed about their anticoagulation preference and discharged home with their preferred anticoagulant. Patients were followed up six weeks postoperatively to assess for medication adherence and adverse events. <h3>Measurements and Main Results</h3> 42 patients were included in the study with a mean BMI of 48.7 ± 7.32 kg/m². One patient had an abdominal hysterectomy, all others underwent robotic hysterectomy. Significantly more patients chose apixaban over dalteparin (30/42, p = 0.008). Route of administration was the most common reason for choosing apixaban, with doctor recommendation and medication cost as other commonly cited reasons. For patients choosing dalteparin, the available evidence and known efficacy in people weighing more than 100 kgs were the main reasons for selection. At 6 weeks post-hysterectomy there were no significant differences in rates of medication adherence, postoperative VTE, or clinically relevant bleeding between the groups. <h3>Conclusion</h3> The majority of patients with class III obesity selected apixaban over dalteparin for postoperative VTE prophylaxis. Although apixaban has less data supporting its use in this population, there were no adverse events in this study. Both anticoagulation options should be offered as this supports patient values and preferences in informed decision making and may improve accessibility.