Rate Of Thrombotic Complications Research Articles

Clinical Implications of Low Body Mass Index on Endovascular Lower Extremity Revascularization

ObjectiveThe epidemic of obesity and associated cardiovascular morbidity continues to grow, attracting public attention and healthcare resources. However, the impact of malnutrition and being underweight continues to be overshadowed by obesity, especially in patients with peripheral arterial disease (PAD). This study assesses the characteristics and outcomes of patients with low body mass index (BMI ≤ 18.5) compared to patients with nonobese BMI undergoing peripheral vascular interventions (PVI). MethodsA retrospective analysis of patients undergoing PVI due to PAD registered in the VQI database. Patients were categorized into underweight (BMI ≤ 18.5) and nonobese BMI (BMI=18.5-30). Patients in both groups were matched 3:1 for baseline demographic characteristics, comorbidities, medications, and indications. Kaplan-Meier analysis was done for long-term outcomes. ResultsA total of 337,926 patients underwent PVI, of whom 12,935 (4%) were underweight, 215,728 (64%) were nonobese, and 109,263 (32%) were obese. Underweight patients were more likely to be older, female, smokers, with COPD, and more likely to present with chronic limb-threatening ischemia than nonobese patients. After propensity matching, there were 18,047 nonobese patients and 6,031 underweight patients. There were no significant differences in matched characteristics.Perioperatively, underweight patients were more likely to require a longer hospital length of stay. Underweight patients had statistically significantly higher 30-day mortality compared to patients with nonobese BMI (3% vs. 1.6%, p<0.001) and a higher rate of thrombotic complications. As for long-term outcomes, underweight patients had a higher rate of reintervention (20% vs. 18%, p<0.001) and major adverse limb events (27% vs. 22%, p<0.001). The 4-year rate of amputation-free survival was significantly lower in underweight patients (70% vs. 82% p<0.001), and the 2-year freedom from major amputation (90% vs. 94% p<0.001) showed similar trends with worse outcomes in patients who were underweight. ConclusionsUnderweight patients with PAD are disproportionally more likely to be African American, females, and smokers and suffer worse outcomes after PVI than PAD patients with nonobese BMI. When possible, increased scrutiny and optimization of nutrition and other factors contributing to low BMI should be addressed prior to PVI.

Factor Eight Inhibitor Bypassing Activity as First-line Therapy for Coagulopathy in Cardiac Surgery

ObjectiveTo compare the outcomes of Factor Eight Inhibitor Bypassing Activity (FEIBA) versus Fresh Frozen Plasma (FFP) as the primary treatment for postoperative coagulopathy in cardiac surgery patients. DesignA retrospective, propensity-matched study. SettingA single, tertiary hospital. ParticipantsPatients who underwent non-coronary open-heart surgery with cardiopulmonary bypass between 2015 and 2023. InterventionsNone. Measurements and Main ResultsWe stratified patients into two groups based on whether they received intraoperative FFP or FEIBA, while cases using both were excluded. We analyzed 434 cases, with 197 receiving FFP and 237 receiving FEIBA. After propensity-matching, there was no significant difference in the proportion of the patients who required pRBC transfusions (p=0.08). However, of those who required pRBC transfusions, patients in the FEIBA group required significantly less units of pRBC (p<0.001). Significantly less patients in the FEIBA group required platelet (p<0.001) and cryoprecipitate (p<0.001) transfusions. The FEIBA group showed reduced prolonged postoperative intubation (p=0.05), reduced ICU length of stay (p=0.04), and lower 30-day readmission rates (p=0.03). There were no differences in rates of thrombotic complications between the two cohorts. ConclusionsIn the initial treatment of post-cardiopulmonary bypass coagulopathy, FEIBA may be more effective than FFP in reducing blood product transfusions and readmission rates. Further studies are needed to explore the potential routine use of FEIBA as first line agent in this patient population.

Analyzing the Impact of Concomitant COVID-19 Infection on Outcomes in Trauma Patients.

The impact of COVID-19 infection at the time of traumatic injury remains understudied. Previous studies demonstrate that the rate of COVID-19 vaccination among trauma patients remains lower than in the general population. This study aims to understand the impact of concomitant COVID-19 infection on outcomes in trauma patients. We conducted a retrospective cohort study of patients ≥18years old admitted to a level I trauma center from March 2020 to December 2022. Patients tested for COVID-19 infection using a rapid antigen/PCR test were included. We matched patients using 2:1 propensity accounting for age, gender, race, comorbidities, vaccination status, injury severity score (ISS), type and mechanism of injury, and GCS at arrival. The primary outcome was inpatient mortality. Secondary outcomes included hospital length of stay (LOS), Intensive Care Unit (ICU) LOS, 30-day readmission, and major complications. Of the 4448 patients included, 168 (3.8%) were positive (COV+). Compared with COVID-19-negative (COV-) patients, COV+ patients were similar in age, sex, BMI, ISS, type of injury, and regional AIS. The proportion of White and non-Hispanic patients was higher in COV- patients. Following matching, 154 COV+ and 308 COV- patients were identified. COVID-19-positive patients had a higher rate of mortality (7.8% vs 2.6%; P = .010), major complications (15.6% vs 8.4%; P = .020), and thrombotic complications (3.9% vs .6%; P = .012). Patients also had a longer hospital LOS (median, 9 vs 5days; P < .001) and ICU LOS (median, 5 vs 3days; P = .025). Trauma patients with concomitant COVID-19 infection have higher mortality and morbidity in the matched population. Focused interventions aimed at recognizing this high-risk group and preventing COVID-19 infection within it should be undertaken.

Characterization of the Benefits and Risks of Therapeutic Anticoagulation in Patients Admitted with Severe COVID-19 (CRITAC).

Severe COVID-19 is associated with increased rates of thrombotic complications. Recent provincial recommendations in British Columbia have suggested providing thromboprophylaxis with therapeutic anticoagulation for hospital inpatients with severe COVID-19 who do not have a high risk of bleeding. To characterize the rates of major bleeding, thrombotic events, complications from COVID-19, and adverse effects among patients with severe COVID-19 treated with therapeutic anticoagulation. This retrospective chart review involved patients with laboratory-confirmed COVID-19 who were admitted to 3 sites within a local health authority between April 1 and December 31, 2021, and received therapeutic anticoagulation for thromboprophylaxis. After screening of 1036 patients, 72 patients were included in the study. The mean age of participants was 54 years, 63% (n = 45) were male, and 92% (n = 66) were receiving supplemental oxygen by nasal prongs on admission. The primary outcome, major bleeding, was experienced by 1 patient (1%). Increasing oxygen requirements resulting in progression to high-flow nasal cannula occurred in 11 patients (15%), and 5 patients (7%) required admission to the intensive care unit. One patient (1%) experienced a thrombotic event, and 1 patient (1%) had a minor bleed. The mean duration of hospitalization was 10 (standard deviation 10.8) days. One death occurred during the study period, and no cases of heparin-induced thrombocytopenia were observed. In this study of hospital inpatients with severe COVID-19 who were deemed to be at low risk of bleeding and who received therapeutic anticoagulation, there were low rates of both major bleeding and thrombotic events.

692 Impact of Dual Antiplatelet Therapy After Stent-assisted Coiling of Unruptured Aneurysms on Risk of Complications

INTRODUCTION: Despite some consensus on the need for perioperative dual antiplatelet therapy (DAPT) after stent-assisted coiling (SAC), the ideal duration of therapy is not clear. METHODS: Ten institutions retrospectively reviewed data from databases prospectively maintained as part of a collaborative research group. Patients with unruptured intracranial aneurysms treated with DAPT following SAC (excluding flow diverters) between January 1, 2016 and December 31, 2020 with at least 6 months follow-up. Records were reviewed for type and duration of DAPT before and after SAC, type of stent, outcome (mRS), follow-up duration, peri-procedural and delayed complications, and rate of significant in-stent stenosis. Complications were considered “during period of risk” if they occurred during DAPT when short term had completed (hemorrhagic) or after completing DAPT when long term continued (thrombotic). RESULTS: 556 patients were reviewed. 450 met all inclusion criteria. Nine patients treated for fewer than 29 days after SAC and 10 treated 43-89 days were excluded from analysis. 80 were treated with short-term DAPT (30-42 days), 188 with medium term (90-179 days), and 163 with long term (180+ days). There were no significant differences in the rate of thrombotic complications during the period of risk in short (1/80; 1.25%), medium (2/188; 1.1%) or long (0/163; 0%) term groups, but rates of hemorrhagic complications were lower in the short-term group (0/80; 0%) versus medium (3/188; 1.6%) or long (1/163; 0.6%). Longer duration DAPT did not reduce the risk of in-stent stenosis (0%; 2.5%; 3.2%). CONCLUSIONS: Continuing DAPT beyond 42 days after SAC did not reduce the risk of thrombotic complications or in-stent stenosis and may increase the risk of hemorrhagic complications. It may be reasonable to discontinue DAPT after 42 days following SAC.

Periprocedural Anticoagulation Management of Patients Undergoing Colonoscopy with Polypectomy.

Introduction/Objective Colonoscopy with polypectomy is an integral component of colorectal cancer screening. There are limited data and consensus on periprocedural anticoagulation management, especially regarding bleeding risk with uninterrupted anticoagulation and thromboembolic risk with interruption. Our aim was to determine the incidence of bleeding and thromboembolic complications among colon screening participants undergoing colonoscopy following implementation of a novel patient care pathway for standardized periprocedural anticoagulation management. Methods We conducted a retrospective study including all participants (age 50-74) on an oral anticoagulant (e.g., vitamin K antagonists, direct oral anticoagulants) referred to the British Columbia Colon Screening Program for colonoscopy following abnormal fecal immunochemical test in a 6-month period (March-August 2022). Data relating to their specific periprocedural anticoagulant management and colonoscopy results including method of polypectomy were obtained. Primary outcomes were major bleeding and arterial or venous thromboembolic events from time of oral anticoagulant interruption until 14 days of postcolonoscopy. Secondary outcomes included nonmajor and minor bleeding, acute coronary syndrome, emergency room visit, hospital admission, and death due to any cause. Results Over the 6-month period, 162 participants completed standardized periprocedural anticoagulation management, colonoscopy ± polypectomy, and 14-day follow-up. One (0.6%) had a major bleeding event and one (0.6%) had an arterial thromboembolic event. Conclusions A novel patient care pathway for standardized periprocedural anticoagulation management with a multidisciplinary team is associated with low rates of major bleeding and thrombotic complications after colonoscopy with polypectomy.

Distal Versus Proximal Radial Intervention; Is It Really Worth of It?

Objectives: Distal transradial approach (dTRA) is a promising technique with a decreased risk of radial artery occlusion and puncture-related injuries. There has been no data which compare dTRA and proximal transradial approach (pTRA) in Turkish population group, so far. Thus, researchers aimed to compare the efficacy and safety of the dTRA versus the conventional pTRA in coronary procedures in this study. Methods: Between September 2021 and June 2022, patients scheduled for transradial angiography at a tertiary cardiac center were enrolled in this study. Patients were randomly selected to undergo coronary imaging using either the distal dTRA or the conventional pTRA in equal numbers. A total of 79 patients were randomized to the proximal approach, and 77 patients were randomized to the dTRA. The primary endpoint was defined as procedural failure. Results: The success rate of cannulation of the dTRA was significantly lower compared to proximal pTRA (pTRA [89.6%] and pTRA [79%] p=0.002). The rate of radial artery thrombotic complications was not different between groups (proxymal %10.6 vs. distal %5.8, p=0.288). The time of cannulation and total procedural time were longer in the dTRA group (20–40 min, median 25 min) compared to the proximal radial group (15–30 min, median 20 min) p = 0.005. However, this did not affect the total scope time duration 3.3 min. (1.6–6.4) versus 2.4 min (1.6–3.7). Conclusion: dTRA has a relatively long access time with no advantages in terms of thrombotic complications in the radial artery.

Management of DOAC-related bleeding in cancer patients: a single center-case series.

Venous thromboembolism (VTE) and stroke carry significant mortality and morbidity in cancer patients. Direct oral anticoagulants (DOACs) have been demonstrated to be effective for the treatment of VTE and prevention of stroke in atrial fibrillation (AF). Bleeding rates are variable and are based on the cancer type and the patient's specific risk factors. There are approved specific antidotes for DOAC-associated bleeding. Other strategies are available for bleeding reversal, including the use of prothrombin complex concentrate (PCC). No randomized studies have compared head-to-head the efficacy and safety of reversal agents. We aim to examine the safety and effectiveness of hemostatic agents in cancer patients with DOAC-related major bleeding. A retrospective chart review study of patients at MD Anderson Cancer Center with DOAC-related major bleeding between 2014 and 2019. Bleeding severity and clinical hemostasis were described based on ISTH guidelines and the Sarode criteria, respectively. The rates of thrombotic complications and mortality at 30-day from the index bleeding event were described. We identified 23 patients with DOAC-related major bleeding; 14 patients received PCC and 9 patients received andexanet alfa. The most common sites of bleeding were the gastrointestinal tract and intracranial. Effective hemostasis and 30-day mortality were similar to reported results from other reports of outcomes of reversal agents for DOAC related-bleeding in non-cancer patients. One patient in each treatment group experienced a thrombotic event. Further larger scale studies are needed to confirm our findings in cancer patients.

Strategies to reduce rates of severe endothermal heat-induced thrombosis following radiofrequency ablation

ObjectiveEndothermal heat-induced thrombosis (EHIT) is a potential complication of radiofrequency ablation (RFA). Data on effective prophylaxis of EHIT are limited. In 2018, a high-volume, single institution implemented strategies to decrease the incidence of EHIT, including a single periprocedural prophylactic dose of low-molecular-weight heparin to patients with a great saphenous vein (GSV) diameter of ≥8 mm or saphenofemoral junction (SFJ) diameter of ≥10 mm and limiting treatment to one vein per procedure. The size threshold was derived from existing literature. The study objective was to evaluate the effects of these institutional changes on thrombotic complication rates after RFA. MethodsA retrospective cohort control study was conducted using the Vascular Quality Initiative database. Data were collected for patients who underwent RFA with a GSV diameter of ≥8 mm or SFJ diameter of ≥10 mm from January 2015 to July 2022. The clinical end points were thrombotic complications (ie, thrombophlebitis, EHIT, deep vein thrombosis) and bleeding complications. Patient demographic and procedural variables were included in the analysis, and significant variables after univariable logistic regression were included in a multivariable logistic regression. ResultsAfter the policy change, the overall vein center EHIT rate decreased from 2.6% to 1.5%, with a trend toward significance (P = .096). The inclusion criterion of a GSV diameter of ≥8 mm or an SFJ diameter of ≥10 mm yielded 845 patients, of whom 298 were treated before the policy change and 547 after. There was a significant reduction in the rate of EHIT classified as class ≥III (2.34 vs 0.366; P = .020) after the institutional changes. Treatment of two or more veins and an increased vein diameter were associated with an increased risk of EHIT (P = .049 and P < .001, respectively). No significant association was found between periprocedural anticoagulation and all-cause thrombotic complications or EHIT (P = .563 and P = .885, respectively). ConclusionsThe institutional policy changes have led to lower rates of EHIT, with a reduction in severe EHIT rates in patients with an ≥8-mm diameter GSV or a ≥10-mm diameter SFJ treated with RFA. Of the changes implemented, restricting treatment to one vein was associated with a reduction in severe EHIT. No association was found with periprocedural low-molecular-weight heparin, although a type 2 error might have occurred. Alternative strategies to prevent thrombotic complications should be explored, such as increasing the dosage and duration of periprocedural anticoagulation, antiplatelet use, and nonpharmacologic strategies.

Thrombosis and Bleeding Risk Scores Are Strongly Associated with Mortality in Hospitalized Patients with COVID-19: A Multicenter Cohort Study.

Background: Internationally established guidelines mention pharmacological prophylaxis for all hospitalized COVID-19 patients. However, there are concerns regarding the efficacy and safety of anticoagulants. This study investigated the associations between thrombosis/bleeding risk scores and clinical outcomes. Methods: We conducted a retrospective review of adult patients admitted to two hospitals between 2021 and 2022. We analyzed clinical data, laboratory results, low molecular weight heparin (LMWH) use, thrombosis, bleeding, and 30-day survival. Results: Of the 160 patients, 69.4% were female, and the median age was 59 years. The rates of thrombotic complications and mortality were 12.5% and 36.3%, respectively. LMWH prophylaxis was administered to 73 of the patients (45.6%). The patients with high Padua prediction scores (PPS) and high IMPROVEVTE scores had a significantly higher risk of venous thromboembolism (VTE) compared to those with low scores (30.8% vs. 9.0%, p = 0.006 and 25.6% vs. 7.7%, p = 0.006). Similarly, elevated IMPROVEVTE and IMPROVEBRS scores were associated with increased mortality (hazard ratios of 7.49 and 6.27, respectively; p < 0.001). Interestingly, LMWH use was not associated with a decreased incidence of VTE when stratified by risk groups. Conclusions: this study suggests that COVID-19 patients with high thrombosis and bleeding risk scores have a higher mortality rate.

Device Related Thrombosis and Bleeding in Pediatric Health Care: A Meta-analysis.

The risk of invasive device-related thrombosis and bleeding contributes to morbidity and mortality, yet their prevalence by device-types is poorly understood. This study aimed to estimate pooled proportions and rates of thrombotic and bleeding complications associated with invasive devices in pediatric health care. Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched. Cohort studies and trials published from January 2011 to June 2022, including (1) indwelling invasive devices, (2) pediatric participants admitted to a hospital, (3) reporting thrombotic and bleeding complications, and (4) published in English, were included. Meta-analysis of observational studies in epidemiology guidelines for abstracting and assessing data quality and validity were used. Device-specific pooled thromboses (symptomatic, asymptomatic, unspecified) and bleeding (major, minor). Of the 107 studies, 71 (66%) focused on central venous access devices. Symptomatic venous thromboembolism in central venous access devices was 4% (95% confidence interval [CI], 3-5; incidence rate 0.03 per 1000 device-days, 95% CI, 0.00-0.07), whereas asymptomatic was 10% (95% CI, 7-13; incidence rate 0.25 per 1000 device-days, 95% CI, 0.14-0.36). Both ventricular assist devices (28%; 95% CI, 19-39) and extracorporeal membrane oxygenation (67%; 95% CI, 52-81) were often associated with major bleeding complications. This comprehensive estimate of the incidence and prevalence of device-related thrombosis and bleeding complications in children can inform clinical decision-making, guide risk assessment, and surveillance.

Comparative Analysis of the Low-Profile Acclino Stent and the Enterprise Stent for the Treatment of Unruptured Intracranial Aneurysms

ObjectiveIn preliminary studies, advanced intracranial stents appear to have a favorable safety profile for intracranial aneurysm treatment. This dual-center study is a head-to-head comparison of the low-profile Acandis Acclino stent (a third-generation stent) and the first- and second-generation Enterprise stent. MethodsPatients who underwent stent-assisted coiling with either the Enterprise or the Acclino stent for unruptured aneurysms during an 8-year period were enrolled and compared for complications, clinical outcomes, and angiographic results. Primary outcome measures were ischemic stroke rate and mid-term complete occlusion rate. Propensity score adjustment was performed to account for small differences between the groups. ResultsEnterprise and Acclino stents were used in 48 cases each. The overall rate of thrombotic complications was higher in the Enterprise group than in the Acclino group (20.8% vs. 4.2%, HR: 6.6, 95%CI: 2.2-20.0, p=0.01, adjusted p<0.01), which translated into a higher rate of major ischemic stroke after Enterprise treatment (6.3% vs. 0%, HR: 2.1, 95%CI: 1.8-2.4, p=0.08, adjusted p<0.01). Mid-term and long-term angiographic follow-up showed complete occlusion rates of 83.3% and 75.0% for Enterprise and 89.2% and 75.9% for Acclino (both p>0.05). Retreatment rates were 10.4% in the Enterprise group and 4.2% in the Acclino group (p=0.42, adjusted p=0.10). ConclusionsThe results indicate a favorable safety profile of the Acclino over the Enterprise, justifying the use of advanced stent systems in clinical practice. However, further comparative studies of the Acclino and other competing stent systems are needed to draw a definitive conclusion on the state of stent-assisted coiling.

Assessing the Feasibility of Thromboprophylaxis with Apixaban in JAK2-Positive Myeloproliferative Neoplasm Patients: The Airport-MPN Trial

Introduction: Thrombosis is a major cause of mortality and morbidity in myeloproliferative neoplasms (MPN). In patients classified as high-risk for thrombosis, current guidelines recommend the use of cytoreduction therapy and low-dose aspirin (e.g., ASA 81 mg daily) to decrease the risk of thrombotic events. However, use of low-dose aspirin is based on limited evidence and is associated with a significant failure rate. Thromboprophylaxis with low-dose direct oral anticoagulants (e.g., apixaban 2.5 mg BID) is an appealing option in MPN, specifically when patients carry the JAK2 mutation, based on the pathophysiology of thrombus formation associated with this driver mutation. In other populations, thromboprophylaxis with a low-dose direct oral anticoagulant has been associated with a reduced risk of arterial and venous thrombotic complications, when compared to low-dose aspirin. Hence, we conducted a pilot trial to assess the feasibility of conducting a randomized controlled trial evaluating the efficacy and safety of apixaban (2.5 mg BID) compared to aspirin (81 mg daily) to prevent thrombotic complications in patients with JAK2-positive MPN (JAK2MPN). Methods: This was a multi-centre, prospective, open-label, blinded endpoint pilot trial (NCT04243122), conducted in three Canadian centers (Ottawa, Calgary, Sherbrooke). Adult patients with a confirmed diagnosis of polycythemia vera, JAK2-positive essential thrombocythemia or JAK2-positive pre-fibrotic myelofibrosis (per local clinical definitions) requiring low-dose aspirin for thromboprophylaxis were eligible. Both patients with an incident diagnosis of JAK2MPN (defined as diagnosed within 1 year) and patients with prevalent disease were targeted for recruitment. Exclusion criteria included a contraindication to thromboprophylaxis or the need for a specific anticoagulant or non-aspirin anti-platelet agent. Patients with a prior history of venous thromboembolism were eligible if they had completed a minimum of 6 months of anticoagulation therapy. Participants were randomized 1:1 to receive apixaban 2.5mg BID or aspirin 81mg daily, along with cytoreductive therapy (per guidelines). The study treatment duration was 6 months. Follow-up occurred at 3, 6 and 7 months after allocation of the study medication. The primary study outcome for feasibility was the monthly recruitment rate per study site over a 6-month follow-up period. Secondary outcomes included rates of thrombotic and bleeding complications. The total estimated sample size was 44 participants (22 per arm). Due to the COVID-19 pandemic, not all sites were able to start recruitment at the same time and the total recruitment period spanned over 24 months. Results: During this 24-month recruitment period, 93 JAK2MPN patients were screened for eligibility. Of these, 69 were eligible and 64% of eligible patients consented to participate. We therefore recruited 44 participants, for a recruitment rate of 0.8 patient per centre per month. Baseline characteristics of participants are presented in Table 1. A total of 29 prevalent cases and 15 incident cases were included. Secondary efficacy, safety, and feasibility outcomes (relating to thrombotic events, bleeding complications, and study compliance) will be available at the ASH Meeting, since all participants will have completed the 6-month treatment duration by October 2023. Discussion: Despite the challenges of the COVID-19 pandemic, we have recruited 100% of our target population. Given the chronicity of MPN, most outpatient clinics functioned remotely during the pandemic, precluding recruitment. Nevertheless, by adapting to the realities of the pandemic, we achieved our recruitment target demonstrating feasibility of a larger trial. The strategies adopted during this pilot trial to recruit participants, such as active screening of clinic lists for potential participants and direct communication with MPN specialists, will be applied to our larger scale trial. Conclusion: This pilot trial demonstrated the feasibility of conducting a large-scale trial evaluating the superiority of apixaban over aspirin for the thromboprophylaxis of JAK2MPN patients. As JAK2MPN are rare diseases, we have partnered with counterparts in France to conduct an international study on the efficacy and safety of direct oral anticoagulant thromboprophylaxis in JAK2MPN patients.

Epidemiology, Outcomes, and 30-Day Readmissions in Acquired Hemophilia

Background: Acquired Hemophilia is a rare bleeding disorder characterized by the presence of autoantibodies (inhibitors) against coagulation factors, mainly targeting factor VIII. It predominantly affects older individuals with underlying autoimmune disorders or malignancies. Achieving hemostasis and inhibiting autoantibody production through immunosuppression are the mainstays of treatment. However, overcorrection of bleeding poses a risk of thrombosis, while immunosuppression increases the risk of infectious complications in older patients with co-existing comorbidities. This study sheds light on the epidemiology of acquired hemophilia, including readmission rates and causes of readmission. Methods: We conducted a retrospective cohort study using the Nationwide Readmissions Database from 2016 to 2019 to identify hospitalizations with acquired hemophilia, using the ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) code D68.311. Descriptive analysis was performed to report patient demographics, hospital characteristics, various comorbid conditions, and complications. The all-cause 30-day readmission rate was calculated, excluding index admissions from December and deaths during index admissions. Additionally, primary diagnoses at readmission were identified. The analysis produced national estimates after applying weights, utilizing the methodology provided by the Healthcare Cost and Utilization Project. Results: Out of 1,450 admissions for acquired hemophilia between 2016 and 2019 in the United States, 803 (55.4%) were males, and 857 (59.1%) belonged to the age group of 61-80 years, with a median age at admission of 73 years. Furthermore, the majority were admitted to a teaching hospital (83.5%), with the highest quintile of acquired hemophilia-specific hospital volumes (43.8%) in a large metropolitan area with at least 1 million residents (59.8%). Although 20.9% had an underlying solid malignancy, only 28.5% had an otherwise high comorbidity burden with the Charlson comorbidity index of &amp;gt;3. Underlying hematologic malignancy was reported in 3.9% of admissions, and 13.5% had a diagnosis of an autoimmune disease. Regarding complications, acute myocardial infarction occurred in 9.5%, disseminated intravascular coagulation was noted in 1.2%, intracranial hemorrhage in 1.5%, ischemic stroke in 2.5%, and venous thromboembolism in 4.4%, with 30.2% of admissions experiencing some form of bleeding. The median length of stay was 7 days, and 101 deaths occurred during the index admission, resulting in a 7% inpatient mortality rate. Out of 1,349 patients who were discharged alive, 371 were readmitted within 30 days, with a 30-day readmission rate of 27% (table 1). The median time to readmission was 10 days (interquartile range 5-18), and the median length of stay during readmission was 7 days (interquartile range 3-14), with 10.8% mortality during readmission. The median hospitalization charges were $11,3008 for both index admissions and readmissions. After omitting readmissions coded as hemophilia, infection (30.8%), followed by bleeding (28.2%), was the most common cause for readmission (figure 1). Conclusion: The study highlights a high rate of bleeding and thrombotic complications in acquired hemophilia, necessitating a careful approach to factor replacement for achieving hemostasis. Moreover, bleeding and infection are the primary reasons for the elevated 30-day readmission rate of 27%, and there is an additional 11% mortality during readmission, indicating a significant incidence of treatment-related toxicity and disease relapse.

Outcomes of Geriatric Burn Patients Presenting to the Trauma Service: How Does Frailty Factor in?

IntroductionFrailty has been known to negatively affect the outcomes of geriatric trauma patients. However, there is a lack of data on the effect of frailty on the outcomes of geriatric trauma patients with concomitant burn injuries. The aim of our study was to compare the outcomes of frail versus nonfrail geriatric trauma patients with concomitant burn injuries. MethodsWe performed a retrospective analysis of American College of Surgeons Trauma Quality Improvement Program (2018). We included geriatric (≥65 y) trauma patients who sustained a concomitant burn injury with ≥10% Total Body Surface Area affected. Patients with body region-specific AIS ≥4 were excluded. Patients were stratified into Frail and Nonfrail, using 5-factor modified Frailty Index. Primary outcomes measured were mortality. Secondary outcomes measured were complications, and hospital and intensive care unit (ICU) length of stay (LOS). Multivariable logistic regression was performed to identify independent predictors of mortality. ResultsA total of 574 patients were identified, of which 172(30%) were Frail. Mean age was 74 ± 7 y and median [interquartile range] ISS was 3[1-10]. Overall, the rate of mortality was 23% and median hospital LOS was 14[3-31]. After controlling for potential confounding factors, frailty was not identified as an independent predictor of mortality (adjusted odds ratio:1.059, P = 0.93) and complications (adjusted odds ratio:1.10, P = 0.73). However, frail patients had longer hospital (β: 5.01, P = 0.002) and ICU LOS (β: 2.12, P < 0.001). ConclusionsAmong geriatric trauma patients with concomitant burn injuries, frailty is associated with longer hospital and ICU LOS, and higher rates of thrombotic complications, but not higher mortality or overall complications. Future research should investigate the impact of early assessment of frailty as well as tailored interventions on outcomes in this population.

Analysis of fibrinolytic shutdown in trauma patients with traumatic brain injury

BackgroundCoagulation profiles following major trauma vary depending on injury pattern and degree of shock. The physiologic mechanisms involved in coagulation function at any given time are varied and remain poorly understood. Thromboelastography (TEG) has been used evaluate coagulation profiles in the trauma population with some reports demonstrating a spectrum of fibrinolysis to fibrinolytic shutdown on initial presentation. The objective of this study was to evaluate the fibrinolytic profile of patients with TBI using thromboelastography (TEG). We hypothesized that patients with TBI would demonstrate low fibrinolytic activity. MethodsAll trauma activations at an ACS-verified level 1 trauma center received a TEG analysis upon arrival from December 2019 to June 2021. A retrospective review of the results and outcomes was conducted, and TBI patients were compared to patients without TBI. Linear regression was used to evaluate the effect of patient and injury factors on fibrinolysis. Hyperfibrinolysis was defined as LY30 ​> ​7.7%, physiologic fibrinolysis as LY30 0.6–7.7%, and fibrinolytic shutdown as LY30 ​< ​0.6%. ResultsA total of 1369 patients received an admission TEG analysis. Patients with TBI had a significantly higher median ISS (16 vs. 8, p ​< ​0.001), lower median admission Glasgow Coma Scale (14 vs. 15, p ​< ​0.001), longer intensive care unit length of stay (3 vs. 2 days, p ​< ​0.0001), increased ventilator days (216 vs. 183, p ​< ​0.001), higher mortality (14.6% vs. 5.1%, p ​< ​0.001), but lower shock index (0.6 vs. 0.7, p ​< ​0.0001) compared to those without TBI. Median LY30 was found to be decreased in the TBI group (0.1 vs. 0.2, p ​= ​0.0006). Patients with TBI were found to have a higher rate of fibrinolytic shutdown compared those without TBI (68.7% vs. 63.5%, p ​= ​0.054). ISS, sex, and shock index were found to be predictive of LY30 on linear regression, but TBI was not (Β: 0.09, SE: 0.277, p ​= ​0.745). The rate of DVT/PE did not appear to be elevated in patients with TBI (0.8%) and without TBI (1.2%). ConclusionsTrauma patients with and without TBI were found to have high rates of fibrinolytic shutdown. Although there was a high incidence of fibrinolytic shutdown, it did not appear to have an impact on the rate of thrombotic complications. The clinical significance of these results is unclear and differs significantly from recent reports which demonstrated that TBI is associated with a 25% rate of fibrinolytic shutdown. Further investigation is needed to better define the fibrinolytic pathway in patients with trauma and TBI to develop optimal treatment algorithms.

Comparison of Supraflex Cruz 60 μm Versus Ultimaster Tansei 80 μm Stent Struts in High Bleeding Risk PCI Patients: Study design and Rational of Compare 60/80 HBR trial

Up to 45% of patients who underwent percutaneous coronary intervention (PCI) may have a high bleeding risk (HBR), depending on the bleeding risk definition.1 This condition is often associated with an enhanced risk of thrombotic events with a negative impact on short- and long-term outcomes,2-8 making the choice of an appropriate antithrombotic regimen after PCI particularly challenging. Advances in stent technologies, in which the introduction of newer generations of thinner strut drug-eluting stents (DES), have significantly reduced the rate of thrombotic complications and may justify a shorter dual antiplatelet therapy (DAPT) duration. Both in vitro and in vivo studies have shown that local hemodynamic factors may critically affect the natural history of atherosclerosis. Strut thickness correlates with flow disturbances and endothelial shear stress. Flow separation within struts determines areas of recirculation with low endothelial shear stress which promotes local concentration of activated platelets.9 By mitigating inflammation, vessel injury, and neointimal proliferation, thin and streamlined struts have been associated with faster vascular healing and re-endothelization and have resulted in lower rates of thrombotic events after PCI.10,11 The use of thin strut and ultra-thin strut stents may lead to a favorable trade-off in bleeding and ischemic events in patients with HBR. However, dedicated studies evaluating the performance of thin strut versus ultrathin strut stents in patients with HBR are lacking.

Homocysteine, cancer and oncothrombosis

Introduction. Hyperhomocysteinemia (HHC) is one of the arms in the pathogenesis of thrombotic complications in female cancer patients.Aim: to assess an HHC-related impact to developing thrombotic complications in patients with malignant neoplasms of the female genital organs and breast cancer.Materials and Methods. There were retrospectively evaluated the data collected from 236 patients: with ovarian tumors (n = 63), cervical cancer (n = 51), breast tumors (n = 64), malignant neoplasms of the uterine body (n = 58). The control group consisted of 50 women without malignant neoplasms. The analysis of homocysteine (HC) concentration, the frequency of polymorphisms of the genes encoding folate cycle enzymes MTHFR C677T, MTHFR A1298C, MTRR A66G, MTR A2756G as well as the rate of thrombotic complications was carried out. A risk of blood HC level-related thrombotic complications was assessed.Results. Plasma HC concentration comprised ≥ 22 μmol/l in 30.5 % of patients. Thrombotic complications within one year after discharge from the hospital were developed in 15.3 % cases. The risk of thrombotic complications turned out to be higher in patients with elevated plasma HC level (≥ 22 μmol/l) (odds ratio = 2.99; 95 % confidence interval = 1.11–8.08). No significantly increased prevalence of polymorphisms in the genes encoding folate cycle enzymes among female cancer patients was detected.Conclusion. Monitoring HC level in female cancer patients contributes separately to predict a likelihood of thrombotic complications. Prescribing drugs that reduce HC level (folic acid) and monitoring its concentration in female cancer patients during therapy, including chemotherapy, can potentially lower an incidence of thrombotic complications.

Indicators of endothelial dysfunction and the rate of thrombotic complications in patients with type 2 diabetes mellitus at different periods after COVID-19

Introduction. Damage to the vascular endothelium and hypercoagulation are two of the main causes of post-­COVID-19 complications. The aim of our study was to evaluate endothelial dysfunction and thrombotic complications at different periods after COVID-19 in patients with type 2 diabetes mellitus. Patients and methods. We conducted a cross-­sectional study of 135 patients with type 2 diabetes mellitus who applied for inpatient treatment at the RSSPMCE clinic (Tashkent, Uzbekistan) in the period from 3 to 24 months after the acute period of COVID-19. The following laboratory parameters were assessed: fibrinogen, INR, APTT, D-dimer, von Willebrand factor, and cell adhesion molecules (VCAM-1, ICAM-1). Results. Despite normal or near-normal INR, APTT and fibrinogen levels, many patients had elevated levels of D-dimer (41.4 % of cases), von Willebrand factor (27.6 % of cases) and vascular cell molecules up to 24 months after infection. The concentrations of ICAM-1 and VCAM-1 did not have statistically significant correlations with the degree of compensation of diabetes mellitus (HbA1c level). At various times after COVID-19, cases of ischemic forms of diabetic foot syndrome and thrombosis affecting the cavernous sinus and upper extremities were recorded. Conclusion. Taking into account the results obtained, patients with type 2 diabetes mellitus after SARS-CoV-2 infection require careful monitoring, and, in addition to assessing standard coagulation parameters, determining the level of cell adhesion molecules may have diagnostic value.

236 The Hypercoagulable State in COVID-19 and Implications for Free Flap Surgery in the Lower Limb

Abstract Aim COVID-19 associated coagulopathy is widely documented in severe COVID-19 infection and COVID-19 Vaccine-Induced Thrombotic Thrombocytopaenia. However, much of this evidence relates to macrovascular thrombosis with limited evidence on the impact of previous mild, asymptomatic COVID-19 infection, or vaccination on microvascular thrombosis in free tissue transfer. We compared the rate of thrombotic complications in traumatic lower limb injuries requiring free flap reconstruction in the pre- and post-COVID era. Method Adult patients undergoing lower limb free flap reconstruction were identified at a single centre over two three-month periods (2019 and 2021). Standard thromboprophylaxis was used for all patients (intraoperative intermittent pressure devices, post-operative thromboembolic deterrent stockings, and prophylactic low molecular weight heparin until discharge). Thrombotic complications were recorded and compared using a chi-squared test. Results In the pre-COVID cohort, 51 patients underwent 52 free flaps. One flap (1.9%) suffered anastomotic thrombosis resulting in flap compromise. Post-COVID, 39 patients underwent 43 free flaps. Nine flaps suffered anastomotic thrombosis (21%) and one patient suffered a pulmonary embolus. This increase was statistically significant (p = 0.002). In the post-COVID cohort, four patients had a COVID-19 infection and 25 patients (64%) had at least one dose of a COVID-19 vaccine before free flap surgery. No patients had an active COVID-19 infection on admission. Conclusions In the post-COVID era there was an increased rate of thrombotic complications in lower limb free flap patients. Further research is required to delineate the best course of action when planning free tissue transfer for patients who have had previous COVID-19 infection or vaccination.