Prevention Of Pulmonary Embolism Research Articles

The role of an IVC filter retrieval clinic-A single center retrospective analysis.

Background:Inferior vena cava (IVC) filter placement still plays an essential role in preventing pulmonary embolism (PE) in patients with contraindications to anticoagulant therapy. However, IVC filter placement does have long-term risks which may be mitigated by retrieving them as soon as clinically acceptable. A dedicated IVC filter clinic provides a potential means of assuring adequate follow-up and retrieval.Aim:To assess the efficacy of our Inferior vena cava (IVC) filter retrieval clinic at improving the rate of patient follow-up, effective filter management, and retrieval rates.Materials and Methods:During the period of August 2017 through July 2018, 70 IVC filters were placed at our institution, and these patients were automatically enrolled into our IVC filter retrieval clinic for quarterly follow-up. We retrospectively reviewed data including appropriateness for removal at 3 months, overall retrieval rates, removal technique(s) employed, and technical success.Results:62.9% of the potentially retrievable filters were removed during the study period. The technical success of extraction, using a combination of standard and advanced techniques, was 91.7%. Overall, 15% of the patients were lost to follow-up.Conclusion:Our findings add to the growing body of literature to support the need for a robust IVC filter retrieval clinic to ensure adequate follow-up and timely retrieval of IVC filters.

453Use of Non-vitamin K antagonist Oral Anticoagulants in a real-world setting: a community pharmacy-based study

Abstract Background The emergence of non-vitamin K antagonist oral anticoagulants (NOAC) has caused a paradigm shift in anticoagulation therapy, with NOAC being increasingly used compared to vitamin K antagonists. Despite the numerous RCTs with NOAC, further follow-up on how this high risk new drug class is used in real-world clinical practice is warranted. Purpose This study aimed to describe NOAC use in a primary care sample of long-term NOAC users, and investigated (i) adherence, (ii) patients' perceptions, (iii) drug interactions and (iv) appropriateness of dosing. Methods A cross-sectional observational study was conducted in 158 community pharmacies. Participants were home-dwelling adults treated with a NOAC for at least one year. They completed a questionnaire collecting data on socio-demographics, clinical characteristics, current medication use, self-reported adherence to NOAC (via Medication Adherence Report Scale, MARS), and beliefs and perceptions about NOAC (via Beliefs about Medicines Questionnaire, BMQ). Adherence to NOAC (self-reported (MARS) and calculated using pharmacy dispensing data (Medication Possession Ratio (MPR)); patients' beliefs and perceptions about NOAC (BMQ); and prevalence of drug interactions and inappropriate dosing (using the recommendations in the summary of product characteristics (SmPC) and the 2018 European Heart Rhythm Association (EHRA) Practical Guide) were assessed. Results Participants (n=766) had a mean age of 76.2±8.8 years, several co-morbidities (median of 5 (IQR 4–6)) and high thromboembolic risk (median CHA2DS2-VASc score of 4 (IQR 3–4)). The majority (93.5%) used NOAC for non-valvular atrial fibrillation, while the other 6.5% used it for the prevention of recurrent deep vein thrombosis or pulmonary embolism. Forty point five percent of the study sample used rivaroxaban, 36.2% apixaban, 21.1% dabigatran and 2.2% edoxaban. About 85% was adherent according to MPR (MPR ≥80%) and self-reported adherence was also high (mean MARS score 24.6±1.0). Two-thirds reported at least one adverse event of the NOAC, with easy bruising/bleeding being most prevalent (40.2% of patients). BMQ showed that 91.3% of patients favoured the “necessity” over the “concerns” of NOAC use. Thirty-one percent of patients had ≥1 drug interaction(s) with NOAC; amiodarone (10.4% of patients), antiplatelet agents (9.7%) and NSAIDs (9.0%) were the most common interacting drugs. NOAC dosing was inappropriate in 15.9% of patients according to SmPC and in 23.1% according to EHRA. Intriguingly, underdosing was more common using the SmPC as reference, while overdosing was more common using the EHRA guideline. Conclusions This real-world analysis of NOAC use revealed high adherence and necessity beliefs, drug interactions in 30% of patients, and suboptimal dosing in about one fifth of patients. These findings can inform the design of targeted community pharmacist interventions to improve quality of NOAC use.

Guidance for Transitioning Among Anticoagulants.

Guidance for Transitioning Among Anticoagulants.

Pharmacokinetic Properties of Rivaroxaban in Healthy Human Subjects.

Direct oral anticoagulants (DOACs) have predictable pharmacokinetics and pharmacodynamics, limited potential for drug to drug interactions, and can be given at fixed doses without the need for routine coagulation monitoring, which makes them a very attractive alternative to vitamin K antagonists. DOACs act by specifically targeting a single coagulation factor, such as Factor Xa or thrombin. Rivaroxaban is a direct Factor Xa inhibitor and has been approved for use in several thromboembolic disorders, such as the prevention of stroke and systemic embolism in adults with non-valvular atrial fibrillation and the prevention of recurrent deep vein thrombosis and pulmonary embolism in adult patients. This review aimed to provide an overview of the mechanism of action of rivaroxaban and outline its pharmacokinetic properties (absorption, distribution, metabolism, and excretion) in healthy adult subjects.

Prophylactic inferior vena cava filters for operative pelvic fractures: a twelve year experience.

Conflicting evidence exists regarding the role of inferior vena cava filters (IVCFs) in the prevention of pulmonary embolism. The aim of this study was to review an institutional policy of prophylactic IVCF placement in all operative pelvic and acetabular fractures as a means of preventing PE by comparing it to a historical prepolicy period of significantly less aggressive IVCF placement. The trauma registry of a single level 1 trauma center was retrospectively queried for all pelvic or acetabular fractures for the prepolicy and intervention periods as defined as January 2003-December 2008 and January 2009-December 2014, respectively-yielding 231 patients for analysis. The primary and secondary outcomes measured were the incidence of PE and deep vein thrombosis. The rate of prophylactic IVCF insertion significantly increased during the study period (p < 0.001). The incidence of pulmonary embolism (1.8% vs. 5.1%, p = 0.351) and DVT (19.3% vs. 10.3%, p = 0.231) were not significantly different when comparing the prepolicy and intervention cohorts. In patients with operative fractures, a nonsignificant trend of increasing incidence of DVTs was appreciated in patients with a prophylactic IVCF versus those without prophylactic IVCF (13 vs. 2, p = 0.222). A policy of increased use of prophylactic IVCFs in patients with operative pelvic and acetabular fractures failed to reduce the incidence of PE or DVT. In contrast, several case reports and institutional series have published several risks associated with IVCF placement including failure to retrieve temporary IVCF. The benefit of prophylactic IVCF in this patient population is unclear.

“Death Knell” for Prophylactic Vena Cava Filters? A 20-Year Experience with a Venous Thromboembolism Guideline

The role of prophylactic vena cava filters (pVCFs) in trauma patients remains controversial. After 20 years of data collection and experience, we reviewed our venous thromboembolism guideline for the efficacy of pVCFs in preventing pulmonary embolism (PE). A retrospective cohort study was performed using our Level I trauma center registry from January 1997 thru December 2016. This population was then divided by the presence of pVCFs. Univariate analysis was performed comparing the incidence of PEs, deep vein thrombosis, and mortality between those with and without a pVCF. There were 35,658 patients identified, of whom 2 per cent (n = 847) received pVCFs. The PE rate was 0.4 per cent in both groups. The deep vein thrombosis rate for pVCFs was 3.9 per cent compared with 0.6 per cent in the no-VCF group (P < 0.0001). Given that there was no difference in the rates of PEs between the cohorts, the subset of patients with a PE were analyzed by their risk factors. Only ventilator days > 3 were associated with a higher risk in the no-pVCF group (0.2 vs 1.5%, P = 0.033). pVCFs did not confer benefit reducing PE rate. In addition, despite their intended purpose, pVCFs cannot eliminate PEs in high-risk trauma patients, suggesting a lack of utility for prophylaxis in this population.

The Clinical Rationale for the Sentry Bioconvertible Inferior Vena Cava Filter for the Prevention of Pulmonary Embolism.

The Sentry inferior vena cava (IVC) filter is designed to provide temporary protection against pulmonary embolism (PE) during transient high-risk periods and then to bioconvert after 60 days after implantation. At the time of bioconversion, the device's nitinol arms retract from the filtering position into the caval wall. Subsequently, the stable stent-like nitinol frame is endothelialized. The Sentry bioconvertible IVC filter has been evaluated in a multicenter investigational-device-exemption pivotal trial (NCT01975090) of 129 patients with documented deep vein thrombosis (DVT) or PE, or at temporary risk of developing DVT or PE, and with contraindications to anticoagulation. Successful filter conversion was observed in 95.7% of patients at 6 months (110/115) and 96.4% at 12 months (106/110). Through 12 months, there were no cases of symptomatic PE. The rationale for development of the Sentry bioconvertible device includes the following considerations: (1) the period of highest risk of PE for the vast majority of patients occurs within the first 60 days after an index event, with most of the PEs occurring in the first 30 days; (2) the design of retrievable IVC filters to support their removal after a transitory high-PE-risk period has, in practice, been associated with insecure filter dynamics and time-dependent complications including tilting, fracture, embolization, migration, and IVC perforation; (3) most retrievable IVC filters are placed for temporary protection, but for a variety of reasons they are not removed in any more than half of implanted patients, and when removal is attempted, the procedure is not always successful even with advanced techniques; and (4) analysis of Medicare hospital data suggests that payment for the retrieval procedure does not routinely compensate for expense. The Sentry device is not intended for removal after bioconversion. In initial clinical use, complications have been limited. Long-term results for the Sentry bioconvertible IVC filter are anticipated soon.

Apixaban: A Clinical Pharmacokinetic and Pharmacodynamic Review.

Apixaban is an oral, direct factor Xa inhibitor that inhibits both free and clot-bound factor Xa, and has been approved for clinical use in several thromboembolic disorders, including reduction of stroke risk in non-valvular atrial fibrillation, thromboprophylaxis following hip or knee replacement surgery, the treatment of deep vein thrombosis or pulmonary embolism, and prevention of recurrent deep vein thrombosis and pulmonary embolism. The absolute oral bioavailability of apixaban is ~ 50%. Food does not have a clinically meaningful impact on the bioavailability. Apixaban exposure increases dose proportionally for oral doses up to 10 mg. Apixaban is rapidly absorbed, with maximum concentration occurring 3–4 h after oral administration, and has a half-life of approximately 12 h. Elimination occurs via multiple pathways including metabolism, biliary excretion, and direct intestinal excretion, with approximately 27% of total apixaban clearance occurring via renal excretion. The pharmacokinetics of apixaban are consistent across a broad range of patients, and apixaban has limited clinically relevant interactions with most commonly prescribed medications, allowing for fixed dosages without the need for therapeutic drug monitoring. The pharmacodynamic effect of apixaban is closely correlated with apixaban plasma concentration. This review provides a summary of the pharmacokinetic, pharmacodynamic, biopharmaceutical, and drug–drug interaction profiles of apixaban. Additionally, the population-pharmacokinetic analyses of apixaban in both healthy subjects and in the target patient populations are discussed.

PDG5 COMMONLY REPORTED ADVERSE EVENTS ASSOCIATED WITH ANTICOAGULANTS USING FDA ADVERSE EVENT REPORTING SYSTEM DATABASE 2012-2018

Newer oral anticoagulants Dabigatran, Rivaroxaban, Apixaban, and Edoxaban (DOACs) have been used for prevention and treatment of deep vein thrombosis and pulmonary embolisms. DOACs use has risen rapidly because Warfarin has a higher risk of major bleeding. The study objectives were to 1) describe the most commonly reported adverse events (AEs) associated with DOACs and Warfarin, and 2) outline patients’ demographics involved in the AE’s reports. This was a retrospective descriptive time-series study. Drug safety data were extracted from the FDA Adverse Event Reporting System (FAERS). Study period was from first quarter 2012 to second quarter 2018. Number of AEs and patient cases were calculated and compared among study DOAC drugs quarterly and annually. Patients’ age and sex were summarized and compared using R program and SAS/STAT software Version 9.4 (Cary, NC, USA). Total number of AE reports for DOACs was 135,333 for Dabigatran, 336,348 for Rivaroxaban, 170,962 for Apixaban, and 1,969 for Edoxaban for study period. Meanwhile, there were 487,244 AE reports for Warfarin . Mean age (SD) of involved patients was 72.5 (3.9) for Dabigatran, 68.5 (5.3) for Rivaroxaban, 70.6 (5.2) for Apixaban, 70.3 (3.7) for Edoxaban, and 62.5 (4.1) for Warfarin. Proportion of female patients was 46% for Dabigatran, 36% for Rivaroxaban, 47% for Apixaban, 41% for Edoxaban, and 47% for Warfarin. The most common DOACs adverse events included several kinds of hemorrhage, such as gastrointestinal and internal, dyspnea, fatigue, nausea, and headache. In this analysis less commonly AE reported in the literature for DOACs were found including spinal cord, ocular, renal, liver, and kidney problems. The unexpected and severe hemorrhage and bleeding are associated with all four anticoagulants, which shows the need for therapeutic risk management in post-marketing surveillance.

Кровоплин при тромбозах у кавальному венозному колекторі

The paper presents an analysis of the survey results 121 patients with venous thrombosis of caval segment. Inclusion in complex clinical and instrumental examination of patients (ultrasonic duplex scanning and doppler, phlebography, multislice computed tomography with intravenous contrast) of the radionuclide scintigraphy possible to assess anatomical prerequisites compensation collateral venous flow in caval thrombosis collector. The study of the anatomical features of compensation collateral flow caval thrombosis in the venous reservoir allows a differentiated approach to the selection method of preven-tion of pulmonary embolism, ground indications for surgical treatment of deep vein thrombosis in the inferior vena cava sys-tem and prevent chronic venous insufficiency.

Evaluation of global laboratory methods and establishing on-therapy ranges for monitoring apixaban and rivaroxaban: Experience at a single institution.

BackgroundApixaban and rivaroxaban are approved for the prevention and treatment of deep vein thrombosis (DVT), pulmonary embolism (PE), and embolic stroke in atrial fibrillation (AF) patients. The aim of this study was to find appropriate methods of monitoring the anticoagulant effects of are direct oral anticoagulants (DOACs) and establish on‐therapy ranges using conventional tests.MethodsA total of 184 samples were collected from 91 patients receiving DOACs. Concentrations of apixaban and rivaroxaban in plasma were accessed by an anti‐factor Xa chromogenic assay. PT, APTT, antithrombin, D‐dimer, dRVVT screen/confirm, FDP, and fibrinogen levels were measured. On‐therapy ranges were calculated by substituting previously reported trough plasma concentrations of DOACs.ResultsAnti‐factor Xa chromogenic assay‐based DOACs levels were 26.0‐279.5 (115.9 ± 56.5) ng/mL for apixaban at 2.5 mg BID, 19.9‐565.1 (205.3 ± 162.4) ng/mL for apixaban at 5 mg BID, 2.3‐395.3 (205.3 ± 162.4) ng/mL for rivaroxaban at 15 mg OD, 3.6‐494.8 (119.6 ± 95.1) ng/mL for rivaroxaban at 20 mg OD, and 9.6‐431.4 (140.8 ± 113.6) ng/mL for rivaroxaban at 15 mg BID. PT (%), antithrombin, and dRVVT confirm tests showed good correlation with plasma apixaban levels. Plasma rivaroxaban concentrations were correlated well with PT (sec), PT (%),and dRVVT confirm results. On‐therapy ranges established for dRVVT confirm test by linear regression were as follows: 1.32‐1.52 for apixaban 2.5 mg BID, 1.12‐1.75 for apixaban 5 mg BID, 1.11‐1.78 for rivaroxaban 15 mg OD, 1.09‐1.64 for rivaroxaban 20 mg OD, and 1.22‐1.81 for rivaroxaban 20 mg BID.ConclusionsApixaban concentrations were well correlated with PT (%), antithrombin, and dRVVT confirm test. Rivaroxaban concentrations showed good correlation with PT (sec), PT (%), and dRVVT confirm test.

The Angel catheter for the prevention of pulmonary embolism: combining an IVC filter and a triple-lumen central venous catheter

ABSTRACTIntroduction: Pulmonary embolism is common in critical care patients and carries significant morbidity and mortality. Concurrent risk of severe bleeding in this population may prohibit anticoagulation.Areas covered: The Angel Catheter device is a central venous catheter combined with an inferior vena cava filter inserted at the bedside for pulmonary embolism prevention. Our review examines the role of this device, safety, efficacy and the limitations it presents.Expert commentary: We conclude the Angel catheter should be considered in critical care patients with significant risk of pulmonary embolus as bridging therapy until anticoagulation can be safely resumed.

Long-Term Clinical Outcomes of Complicated Retrievable Inferior Vena Cava Filter for Deep Venous Thrombosis Patients: Safety and Effectiveness.

BackgroundInferior vena cava (IVC) filters have proven valuable for the prevention of pulmonary embolism. However, retrieval of IVC filters can be challenging and complicated techniques are needed. The aim of this study was to retrospectively review the outcomes after retrieval of retrievable IVC filters which required complicated retrieval techniques.Material/MethodsThis study was a single-center retrospective observational study. All patients who underwent complicated IVC filter retrieval from September 2012 to May 2016 were included. Patient demographics and filter retrieval procedure were documented. Clinical outcomes and procedure-related complications were evaluated. Villalta score and VEINES-QOL/Sym were recorded to assess post-thrombotic syndrome.ResultsA total of 79 consecutive patients, 37 males and 42 were female, with a mean age of 46.5 years (age range: 22–65 years) were included in this study. IVC filters, with mean indwell time of 108 days (range: 74–157 days), were refractory to standard treatment and underwent complicated IVC filter retrieval. There were 6 serious procedure-related complications: 4 popliteal puncture area hematoma complications and 2 hematuria complications. With a mean follow-up of 20.5 months (range: 18–24 months), no pulmonary embolisms occurred, and 2 patients experienced recurrent deep venous thrombosis. Twenty-seven patients developed post-thrombotic syndrome within the first 2 years after IVC retrieval.ConclusionsComplicated methods can be used to safely remove IVC filters, alleviate filter-related morbidity, and reduce risk for post-thrombotic syndrome. The application of these techniques was safe and effective for patients with refractory IVC filters.

Thrombectomy for acute iliofemoral thrombosis in prevention of pulmonary embolism

Acute thrombosis in the system of the inferior vena cava is one of the most common vascular diseases and is of serious danger as a potential source of one of the most severe complications. In order to assess efficacy of open thrombectomy for embologenic iliofemoral venous thromboses we carried out comparison of the results of open thrombectomy and implantation of cava filters in a total of 119 patients presenting with iliofemoral thrombosis. Open thrombectomy was performed in a total of 59 patients. Of these, 12 patients with segmental thromboses underwent radical thrombectomy and 47 patients with disseminated forms of thrombosis were subjected to partial thrombectomy with plication of the femoral vein. In 5 patients, the operation was supplemented with applying an arteriovenous fistula. Efficacy of operations was assessed with the help of ultrasonographic duplex angioscanning and regression of clinical manifestations. In the remote period, the degree of manifestations of post-thrombotic disease was assessed by means of the Villalta scale. After radical thrombectomy, patency of the iliofemoral segment was preserved in all patients during the whole follow-up period. In the group of patients with partial thrombectomy, 5 (9.5%) patients developed rethrombosis above the placation site at terms from 8 to 12 months. Four-year patency of the iliofemoral segment in this group of patients amounted to 81.5%. In patients with implanted cava filters, neither femoral vein nor iliac segment were patent completely. During the first year, thrombosis of cava filter developed in 9 cases; after 2 years, occlusion of the cava filter was diagnosed in 7 patients. In clinical assessment of the remote results with the use of the Villalta scale in patients after open thrombectomy the symptoms of post-traumatic disease were absent or weakly pronounced. After implantation of the cava filter all patients demonstrated the clinical course of post-traumatic disease, corresponding to 10-15 points. Open thrombectomy for iliofemoral embologenic thromboses performed at specialized departments is a radical method of preventing thromboembolic complications and promotes restoration or improvement of venous blood flow in the extremity.

Kissing Sheath Technique for Permanent Inferior Vena Cava

In patients where anticoagulation therapy is contraindicated, Inferior Vena Cava (IVC) filters are used as an option to prevent Pulmonary Embolism (PE). There are many classifications of Vena Cava filters the two main groups are; those intended for permanent implantation and the other temporary (which are to be retrieved at a later date). Permanent IVC filters are not designed to be removed, unless unexpected clinical circumstances arise. We describe a complex case of retrieval of a permanent IVC filter, though well documented; it is the first of its kind to be recorded in the Caribbean.

Prophylactic use of the Angel® Catheter in a patient with paraneoplastic syndrome scheduled for surgical tumor resection: A case report and literature review

Introductio. The Angel? catheter (BiO2 Medical Inc, San Antonio, Texas, USA) is a novel device that combines a triple lumen central venous catheter with an inferior vena cava filter for prevention of pulmonary embolism (IVC filtercatheter). Case report. We present the case of a 53- yearold male patient with renal carcinoma and a history of recent deep venous thrombosis (DVT) on oral anticoagulation who was scheduled to undergo open radical nephrectomy. Because of concerns about the risks from documented pre-existing DVT, we decided to insert the Angel? catheter preoperatively in order to have central venous access during surgery and also to reduce the risk of perioperative pulmonary embolism. On the first postoperative day, active gastric bleeding was detected and nadroparine was stopped. Before removal of the Angel? catheter, a pre-removal cavagram revealed large thrombus mass in the catheter filter. Because of the presence of the thrombus mass, the catheter was removed surgically, after a permanent vena cava filter was inserted. Conclusion. This case suggests that the use of the Angel? IVC filter/3-lumen central catheter combination could be a reasonable option for pulmonary embolism prophylaxis in the patients at a high risk for DVT, such as the patients with malignant disease, paraneoplastic syndrome and chemotherapy who need to undergo surgery.

Catheter-directed thrombolysis for thrombi in right atrium and upper extremity caused by peripherally inserted central catheters

Introduction: Peripherally inserted central catheters (PICC) are widely applied in clinical practice. One of the foremost complications is the potential risk for thrombosis associated with their use. Especially the thrombi within the cardiac chambers are rarely observed in clinical practice, but they are potentially deadly to patients for pulmonary embolism. There are no evidencebased guidelines for their treatment, and the optimal treatment is controversial (conservative or positive). Case Report: We report the case of a 52-year-old female, who presented with both a right atrial thrombus and upper extremity deep vein thrombi on three days following PICC insertion. After an elaborate surgery with two catheters for thrombolysis and one filter for prevention of pulmonary embolism, the thrombi were dissolved effectively without occurrence of any complications. Conclusion: In summary, regarding the treatment choice of complex thrombi in both right atrium and upper extremity, with the development of vascular surgery and interventional equipment, interventional treatment might be a well-tolerated therapeutic option. The ingenious surgical design of two catheters for thrombolysis and one filter for prevention of pulmonary embolism highlights a safe and feasible treatment for this kind of thrombi with minimal trauma.

Predictors of Chronic Thromboembolic Pulmonary Hypertension

to elucidate predictors of development of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary artery thromboembolism (PTE). We included in this study 210 patients hospitalized withdiagnosis ofsubmassive and massive PTE from 2013 to 2017. In 1to3years after initial hospitalization these patients were invited for control examination. According to results of this examination patients were divided into two groups: with (group 1, n=45) and without (group 2, n=165) signs of CTEPH. Severity ofpulmonary artery vascular bed involvement was assessed bymultislice computed tomography (MSCT) angiography and lung scintigraphy. For detection of thrombosis in the inferior vena cava system we used ultrasound angioscanning. Examination also included echocardiography. Intheprocess of mathematical analysis, the following risk factors for the development of CTEPH embolism were determined: duration of thrombotic history (group 1 - 13.70±2.05 days, group 2- 16.16±1.13days, p=0.015), localization of venous thrombosis in the lower extremities (the most favorable- shin veins, popliteal, and common femoral veins, unfavorable- superficial femoral vein). The choice of the drug for thrombolytic and anticoagulant therapy: streptokinase and urokinase were significantly more effective than alteplase, rivaroxaban was superior to the combination of unfractionated orlow molecular weight heparins with warfarin. Also, risk factors for the development of CTEPH were the initial degree of pulmonary hypertension and tricuspid insufficiency, as well as the positive dynamics of these indicators at the background of thrombolytic oranticoagulant therapy. Of concomitant diseases, significant risk factors for development of CTEPH were grade 3 hypertensive disease, diabetes mellitus, post-infarction cardiosclerosis. Ontheother hand, age, gender, degree of severity at the time of admission, presence ofinfarction pneumonia, surgical prevention of recurrent pulmonary embolism, number of pregnancies and deliveries, history oftrauma and malignancies, cardiac arrhythmias produced nosignificant impact on the development of CTEPH.

Unusual Cause of Acute Drug-Induced Hepatitis

Rivaroxaban is an oral anticoagulant used in non-valvular A-fib, as well as treatment and prevention of DVT and pulmonary embolism (PE). We present a case of reversible acute liver injury; a rare adverse reaction of rivaroxaban. A 62-y.o. female presented to ER with a 2-week history of nausea, early satiety, dull aching RUQ pain, dark urine and normal colored stool. She has history of GERD and recurrent PE, the latest was a month earlier and she was started on rivaroxaban. She has no history of alcohol/acetaminophen use, substance abuse, liver disease, blood transfusion, recent travel or infection. The only positive physical exam finding was mild RUQ tenderness. Initial work up showed markedly elevated LFTs (table). Acute hepatitis profile, monospot test, acetaminophen/alcohol levels, EBV, CMV, CPK, TSH, urine/blood drug screen, autoimmune workup, liver ultrasound with Doppler, CT and MRI abdomen; all were negative. The patient was discharged home with GI follow-up. Few days later, she presented with worsening symptoms including dizziness, poor appetite and nausea. Repeat blood test showed worsening LFTs. Patient was admitted and started on supportive therapy while efforts to determine the cause of elevated LFTs continued. Rivaroxaban-induced acute liver injury was entertained. The drug was stopped and she was switched to enoxaparin for anticoagulation. Her LFTs and symptoms continued to improve over few months after her discharge. The Naranjo Adverse Drug Reaction Probability Scale indicated a probable relationship (score of 6) between rivaroxaban use and acute liver injury. Rivaroxaban is a direct factor Xa inhibitor that may cause bleeding, rash and liver injury. Rivaroxaban is associated with moderate ALT elevation in 1.5% to 3% of patients. Most cases have an onset within 1 to 8 weeks of starting therapy. All patients recover 2 to 4 weeks after stopping rivaroxaban. Cases of acute liver failure, chronic hepatitis or vanishing bile duct syndrome due to rivaroxaban have not been reported in the literature. The exact mechanism of liver injury is unknown, but may be idiosyncratic or immunologic. Rivaroxaban is metabolized in the liver mainly by CYP3A4 and is susceptible to drug-drug interactions. Clinicians should be made aware of this rare side effect as early discontinuation of the drug is essential to prevent morbidity and even mortality. Future research is needed to determine if routine follow up of LFTs is advised in patients on rivaroxaban.2173 Figure 1 No Caption available.

TCT-131 Hemopericardium and Cardiac Tamponade As a Complication of Vena Caval Filters: Systematic Review of Published Literature and the MAUDE Database

Vena caval filters (VCFs) are used for prevention of pulmonary embolism. However, besides the limited evidence of efficacy, their safety profile has not been fully elucidated. Embolization of the filter or filter components to the heart may lead to cardiac perforation, causing hemopericardium and