Receiving Anticoagulation Treatment Research Articles

A Cross-Sectional Study Investigating Clinical Features, Brain Imaging, and Treatment Efficacy in Patients with Cerebral Venous Thrombosis in the Mekong Delta, Vietnam.

Cerebral venous thrombosis (CVT) is a challenging condition with potential long-term consequences, but it is also a treatable disorder that offers the possibility of complete recovery. This study was conducted to comprehensively investigate the clinical features, brain imaging findings, and treatment outcomes of patients diagnosed with cerebral venous thrombosis. Conducted as a cross-sectional descriptive study, patients diagnosed with cerebral venous thrombosis were enrolled at Can Tho Central General Hospital between January 2021 and June 2022. Notably, a substantial proportion of patients (83.4%) exhibited signs of brain damage, with intracranial hemorrhage (50%), brain infarction (30.9%), subarachnoid hemorrhage (16.6%), and hemorrhagic infarct (4.7%) being the predominant findings. Thrombosis primarily affected the superior sagittal sinus (85.7%), transverse sinus (52.4%), and sigmoid sinus (42.8%). All patients received anticoagulation treatment, resulting in a favorable recovery upon hospital discharge for the majority (90.5%), while a small percentage (9.5%) experienced critical illness or death. Our study on cerebral venous thrombosis found diverse clinical presentations, primarily headache. Intracranial hemorrhage was common, affecting superior sagittal, transverse, and sigmoid sinuses. Most patients achieved favorable recoveries with anticoagulation treatment, emphasizing early intervention's importance.

Evaluation of antithrombotic treatment in institutionalized geriatric patients with nonvalvular atrial fibrillation

ObjectiveThe goals of this study were to analyze the type of antithrombotic treatment administered to institutionalized patients with nonvalvular atrial fibrillation (and any ensuing complications) and to evaluate the degree of anticoagulation control achieved with vitamin K antagonists. MethodThis was a prospective observational follow-up study carried out in seven elderly care facilities during 2016. Patients with nonvalvular atrial fibrillation were evaluated for their antithrombotic therapy and any embolic or hemorrhagic events, as well as for mortality. Subjects on anticoagulation treatment with VKAs were evaluated for anticoagulation control, with control considered poor if the mean time in therapeutic range was < 65% when measured with Rosendaal's method or < 60% when determined by the direct method. ResultsOf the 699 residents evaluated, 20.6% had a diagnosis of NVAF. Average age was 85.83 years. Both the cardioembolic (mean CHA2DS2-VASc score: 4.79), and the hemorrhagic (mean HAS-BLED score: 3.04) risk were high. Fifty percent received anticoagulation treatment, mainly with vitamin K antagonists, of whom at least 56% were not within the therapeutic range. Sixteen percent of the residents, the oldest and most functionally and cognitively dependent ones, had not been prescribed any antithrombotic therapy. A higher frequency of hospital admissions induced by cardiovascular and bleeding events was found in these residents, although differences were not statistically significant. ConclusionsHalf of institutionalized geriatric patients with nonvalvular atrial fibrillation are anticoagulated, a third on antiplatelet therapy, and some without any antithrombotic treatment. This study showed that as functionality decreases, treatment strategies are increasingly aimed at therapeutic deintensification. Given that the degree of anticoagulation control with vitamin K antagonists is inadequate in 56% of cases, it is essential to monitor the time in therapeutic range to optimize treatment as needed.

Risks and impacts of thromboembolism in patients with pancreatic cancer.

Patients with pancreatic cancer have a high risk of thromboembolism (TE), which may increase mortality. Most relevant studies have been conducted in Western populations. We investigated risk factors for TE in a predominantly Chinese population of patients with pancreatic cancer, along with effects of TE on overall survival. This retrospective cohort study included patients diagnosed with exocrine pancreatic cancer in Prince of Wales Hospital in Hong Kong between 2010 and 2015. Data regarding patient demographics, World Health Organization performance status, stage, treatment, TE-related information, and time of death (if applicable) were retrieved from electronic medical records. Univariate and multivariable logistic regression analyses were performed to identify risk factors for TE. Survival analyses were performed using Kaplan-Meier analysis and Cox proportional hazards regression. In total, 365 patients were included in the study. The overall incidence of TE (14.8%) was lower than in Western populations. In univariate logistic regression analysis, stage IV disease and non-head pancreatic cancer were significantly associated with TE (both P=0.01). Multivariable logistic regression analysis showed that stage IV disease was a significant risk factor (odds ratio=1.08, 95% confidence interval [CI]=1.00-1.17; P=0.046). Median overall survival did not significantly differ between patients with and without TE (4.88 months vs 7.80 months, hazard ratio=1.08, 95% CI=0.80-1.49; P=0.58) and between patients with TE who received anticoagulation treatment or not (5.63 months vs 4.77 months, hazard ratio=0.72, 95% CI=0.40-1.29; P=0.27). The incidence of TE was low in our Chinese cohort. Stage IV disease increased the risk of TE. Overall survival was not affected by TE or its treatment.

Middle meningeal artery embolization in the management of chronic subdural hematoma in medically complex pediatric neurosurgical patients: technical note.

Middle meningeal artery (MMA) embolization has gained acceptance as a treatment for chronic subdural hematoma (cSDH) in adult patients but has not been well described in pediatric patients. Standard cSDH treatment has historically consisted of burr hole drainage with or without subdural drain placement. However, due to the high rate of recurrence and frequency of comorbidities within this population, as both pediatric and adult patients with cSDH frequently have concurrent cardiac disease and a need for anticoagulant therapies, MMA embolization has increasingly demonstrated its value as both an adjunctive and primary treatment. In this report, the authors present 3 cases of successful MMA embolization in medically complex children at a single institution. MMA embolization was used as a primary treatment modality and as an adjunctive therapy in the acute setting following surgical hematoma evacuation. Two patients were receiving anticoagulation treatment requiring reversal. Technical considerations specific to the pediatric population as well as those common to both the pediatric and adult populations are addressed. Further work is needed to define the optimal indications and outcomes for MMA embolization in children with cSDH.

Venous thromboembolism after spontaneous intracerebral hemorrhage and the status quo of anticoagulation in this population: A retrospective case[sbnd]control study from a tertiary hospital in China

ObjectivePatients with spontaneous intracerebral hemorrhage (sICH) are susceptible to venous thromboembolism (VTE) including pulmonary embolism (PE) and deep venous thrombosis (DVT) due to a variety of risk factors. There are few studies regarding the predictive value of D-dimer for VTE in patients with sICH, and the anticoagulation therapy for these patients are still controversial. The objective of this study is to study the independent predictors of VTE in sICH patients. The rates of anticoagulation therapy and hemorrhagic evens were also investigated. MethodsRetrospective review of patients with sICH admitted to the First Affiliated Hospital of Dalian Medical University from 2012 to 2022 and who developed VTE (PE and/or DVT) during hospitalization. A similar number of sICH patients without VTE were randomly selected into the control group. A variety of clinical characteristics were compared between groups. Univariate and multivariate analyses were performed to identify independent predictors of VTE in patients with sICH. ResultsA total of 270 sICH patients were enrolled in this study, including 132 patients with VTE and 138 patients without VTE. After adjusting for other confounders, the maximum level of D-dimer during hospitalization (odds ratio [OR] 1.061, 95 % confidence interval (CI) 1.014–1.110), Glasgow coma scale (GCS) on admission (OR 1.347, 95 % CI 1.110–1.634), modified Rankin Scale (mRS) at discharge (OR 2.578, 95 % CI 1.546–4.298), neutrophil count (OR 1.056, 95 % CI 1.025–1.088) and hospitalization time (OR 1.089, 95 % CI 1.018–1.164) were independently associated with the sICH patients who developed VTE. The maximum D-dimer plasma level of 5.655 mg/L during hospitalization was the optimal threshold to indicate sICH patients developing VTE with a sensitivity of 83.3 % and a specificity of 67.4 %. No patients with sICH received prophylactic anticoagulation therapy against VTE in the present study. A total of 57.6 % (76/132) of the sICH patients with VTE were administered anticoagulant therapy and the rate of hemorrhagic complication was 9.2 %. ConclusionssICH patients with increased levels of D-dimer, higher GCS scores, higher mRS scores, increased neutrophil counts and longer hospitalization time are more likely to develop VTE complications. Routine and serial monitoring of the D-dimer values may be useful in patients with sICH, and VTE should be considered when the plasma level of D-dimer increases to 5.655 mg/L during hospitalization. In tertiary hospitals in China, the rate of sICH patients with VTE receiving anticoagulation treatment is low. Further studies are necessary to explore the safety and efficacy of VTE therapeutic anticoagulation in patients with sICH.

Integral assays of hemostasis in hospitalized patients with COVID-19 on admission and during heparin thromboprophylaxis.

Blood coagulation abnormalities play a major role in COVID-19 pathophysiology. However, the specific details of hypercoagulation and anticoagulation treatment require investigation. The aim of this study was to investigate the status of the coagulation system by means of integral and local clotting assays in COVID-19 patients on admission to the hospital and in hospitalized COVID-19 patients receiving heparin thromboprophylaxis. Thrombodynamics (TD), thromboelastography (TEG), and standard clotting assays were performed in 153 COVID-19 patients observed in a hospital setting. All patients receiving treatment, except extracorporeal membrane oxygenation (ECMO) patients (n = 108), were administered therapeutic doses of low molecular weight heparin (LMWH) depending on body weight. The ECMO patients (n = 15) were administered unfractionated heparin (UFH). On admission, the patients (n = 30) had extreme hypercoagulation by all integral assays: TD showed hypercoagulation in ~75% of patients, while TEG showed hypercoagulation in ~50% of patients. The patients receiving treatment showed a significant heparin response based on TD; 77% of measurements were in the hypocoagulation range, 15% were normal, and 8% remained in hypercoagulation. TEG showed less of a response to heparin: 24% of measurements were in the hypocoagulation range, 59% were normal and 17% remained in hypercoagulation. While hypocoagulation is likely due to heparin treatment, remaining in significant hypercoagulation may indicate insufficient anticoagulation for some patients, which is in agreement with our clinical findings. There were 3 study patients with registered thrombosis episodes, and all were outside the target range for TD parameters typical for effective thromboprophylaxis (1 patient was in weak hypocoagulation, atypical for the LMWH dose used, and 2 patients remained in the hypercoagulation range despite therapeutic LMWH doses). Patients with COVID-19 have severe hypercoagulation, which persists in some patients receiving anticoagulation treatment, while significant hypocoagulation is observed in others. The data suggest critical issues of hemostasis balance in these patients and indicate the potential importance of integral assays in its control.

Acute arterial thrombosis in anticoagulated patient for acute pulmonary thromboembolism

Acute limb ischemia is rare in patients with venous thromboembolism who already receive anticoagulation treatment. Inflammation is a risk factor for thrombus formation. Patients with active ulcerative colitis, especially at the time of exacerbation, are more prone to thromboembolism, both venous and arterial. The risk for thrombosis is 18% higher, with a higher risk of bleeding. To date, there is no contraindication to any anticoagulant drug in patients with ulcerative colitis. We represent a case of a 73 year - old woman with ulcerative colitis exacerbation, hospitalized initially for pulmonary thromboembolism, that developed acute arterial thrombosis when switched on a novel oral anticoagulant.

Outcomes associated with antithrombotic strategies in heart failure with reduced ejection fraction and sinus rhythm following acute ischemic stroke.

Insufficient data exist regarding the benefit of long-term antiplatelet vs. anticoagulant therapy in the prevention of recurrent ischemic stroke in patients with ischemic stroke and heart failure with reduced ejection fraction (HFrEF). Therefore, this study aimed to compare longitudinal outcomes associated with antiplatelet vs. anticoagulant use in a cohort of patients with stroke and with an ejection fraction of ≤40%. We retrospectively analyzed single-center registry data (2015-2021) of patients with ischemic stroke, HFrEF, and sinus rhythm. Time to the primary outcome of recurrent ischemic stroke, major bleeding, or death was assessed using the adjusted Cox proportional hazards model and was compared between patients treated using anticoagulation (±antiplatelet) vs. antiplatelet therapy alone after propensity score matching using an intention-to-treat (ITT) approach, with adjustment for residual measurable confounders. Sensitivity analyses included the multivariable Cox proportional hazards model using ITT and as-treated approaches without propensity score matching. Of 2,974 screened patients, 217 were included in the secondary analyses, with 130 patients matched according to the propensity score for receiving anticoagulation treatment for the primary analysis, spanning 143 patient-years of follow-up. After propensity score matching, there was no significant association between anticoagulation and the primary outcome [hazard ratio (HR) 1.10, 95% confidence interval (CI): 0.56-2.17]. Non-White race (HR 2.26, 95% CI: 1.16-4.41) and the presence of intracranial occlusion (HR 2.86, 95% CI: 1.40-5.83) were independently associated with the primary outcome, while hypertension was inversely associated (HR 0.42, 95% CI: 0.21-0.84). There remained no significant association between anticoagulation and the primary outcome in sensitivity analyses. In HFrEF patients with an acute stroke, there was no difference in outcomes of antithrombotic strategies. While this study was limited by non-randomized treatment allocation, the results support future trials of stroke patients with HFrEF which may randomize patients to anticoagulation or antiplatelet.

Venographic classification and long-term surgical treatment outcomes for axillary-subclavian vein thrombosis due to venous thoracic outlet syndrome (Paget-Schroetter syndrome)

ObjectiveWe assessed the clinical presentation, operative findings, and surgical treatment outcomes for axillary-subclavian vein (AxSCV) thrombosis due to venous thoracic outlet syndrome (VTOS). MethodsWe performed a retrospective, single-center review of 266 patients who had undergone primary surgical treatment of VTOS between 2016 and 2022. The clinical outcomes were compared between the patients in four treatment groups determined by intraoperative venography. ResultsOf the 266 patients, 132 were male and 134 were female. All patients had a history of spontaneous arm swelling and idiopathic AxSCV thrombosis, including 25 (9%) with proven pulmonary embolism, at a mean age of 32.1 ± 0.8 years (range, 12-66 years). The timing of clinical presentation was acute (<15 days) for 132 patients (50%), subacute (15-90 days) for 71 (27%), and chronic (>90 days) for 63 patients (24%). Venography with catheter-directed thrombolysis or thrombectomy (CDT) and/or balloon angioplasty had been performed in 188 patients (71%). The median interval between symptom onset and surgery was 78 days. After paraclavicular thoracic outlet decompression and external venolysis, intraoperative venography showed a widely patent AxSCV in 150 patients (56%). However, 26 (10%) had a long chronic AxSCV occlusion with axillary vein inflow insufficient for bypass reconstruction. Patch angioplasty was performed for focal AxSCV stenosis in 55 patients (21%) and bypass graft reconstruction for segmental AxSCV occlusion in 35 (13%). The patients who underwent external venolysis alone (patent or occluded AxSCV; n = 176) had a shorter mean operative time, shorter postoperative length of stay and fewer reoperations and late reinterventions compared with those who underwent AxSCV reconstruction (patch or bypass; n = 90), with no differences in the incidence of overall complications or 30-day readmissions. At a median clinical follow-up of 38.7 months, 246 patients (93%) had no arm swelling, and only 17 (6%) were receiving anticoagulation treatment; 95% of those with a patent AxSCV at the end of surgery were free of arm swelling vs 69% of those with a long chronic AxSCV occlusion (P < .001). The patients who had undergone CDT at the initial diagnosis were 32% less likely to need AxSCV reconstruction at surgery (30% vs 44%; P = .034) and 60% less likely to have arm swelling at follow-up (5% vs 13%; P < .05) vs those who had not undergone CDT. ConclusionsParaclavicular decompression, external venolysis, and selective AxSCV reconstruction determined by intraoperative venography findings can provide successful and durable treatment for >90% of all patients with VTOS. Further work is needed to achieve earlier recognition of AxSCV thrombosis, prompt usage of CDT, and even more effective surgical treatment.

Undertreatment of Anticoagulant Therapy in Hospitalized Acute Ischemic Stroke Patients With Atrial Fibrillation.

BackgroundThis study aimed to investigate the prevalence and factors associated with the initiation of oral anticoagulation among patients with acute ischemic stroke (AIS) and concurrent atrial fibrillation (AF) at discharge in China.MethodsWe continuously included hospitalized patients with AIS with an AF diagnosis registered in the computer-based Online Database of Acute Stroke Patients for Stroke Management Quality Evaluation (CASE II) from January 2016 to December 2020 and divided them into a and non-anticoagulant groups according to the medications at discharge. Binary logistic regression was used to determine the factors associated with the prescription of anticoagulants in patients with AF.ResultsA total of 16,162 patients were enrolled. The mean age was 77 ± 9 years, 8,596 (53.2%) were males, and the median baseline National Institute of Health Stroke Scale score was 5 (2–12). Of the 14,838 patients without contraindications of antithrombotic therapy, 6,335 (42.7%) patients were initiated with anticoagulation treatment at discharge. Prior history of hemorrhagic stroke (OR 0.647, p < 0.001) and gastrointestinal bleeding (OR 0.607, p = 0.003) were associated with a lower rate of anticoagulation at discharge. Patients with any intracranial hemorrhage (OR 0.268, p < 0.001), gastrointestinal bleeding (OR 0.353, p < 0.001), or pneumonia during hospitalization (OR 0.601, p < 0.001) were less likely to receive anticoagulants at discharge. Among 7,807 patients with previously diagnosed AF and high risk of stroke (CHA2DS2-VASc ≥2), only 1,585 (20.3%) had been receiving anticoagulation treatment prior to the onset of stroke. However, the mean international normalized ratio (INR) was 1.5 on the first test during hospitalization in patients receiving warfarin. Patients complicated with a previous history of ischemic stroke/transient ischemic attack (TIA; OR 2.303, p < 0.001) and peripheral artery disease (OR 1.456, p = 0.003) were more common to start anticoagulants.ConclusionsLess than half of patients with AIS and concurrent AF initiated guideline-recommended oral anticoagulation at discharge, while only 20% of patients with previously diagnosed AF with a high risk of stroke had been using anticoagulants prior to the onset of stroke, which highlights a large care gap in hospitalized stroke patients and the importance of AF management.

In-hospital Mortality Rates in SARS-CoV-2 Patients Treated with Enoxaparin and Heparin.

АbstrасtObjectivesThis study aimed to investigate in-hospital mortality rates in patients with coronavirus disease (COVID-19) according to enoxaparin and heparin use.MethodsThis retrospective cohort study included 962 patients admitted to two hospitals in Kuwait with a confirmed diagnosis of COVID-19. Cumulative all-cause mortality rate was the primary outcome.ResultsA total of 302 patients (males, 196 [64.9%]; mean age, 57.2 ± 14.6 years; mean body mass index, 29.8 ± 6.5 kg/m2) received anticoagulation therapy. Patients receiving anticoagulation treatment tended to have pneumonia (n = 275 [91.1%]) or acute respiratory distress syndrome (n = 106 [35.1%]), and high D-dimer levels (median [interquartile range]: 608 [523;707] ng/mL). The mortality rate in this group was high (n = 63 [20.9%]). Multivariable logistic regression, the Cox proportional hazards, and Kaplan-Meier models revealed that the use of therapeutic anticoagulation agents affected the risk of all-cause cumulative mortality.ConclusionAge, hypertension, pneumonia, therapeutic anticoagulation, and methylprednisolone use were found to be strong predictors of in-hospital mortality. In elderly hypertensive COVID-19 patients on therapeutic anticoagulation were found to have 2.3 times higher risk of in-hospital mortality. All cause in-hospital mortality rate in the therapeutic anticoagulation group was up to 21%.

P-BN09 Management of isolated splenic vein thrombosis: Risks and benefits of Anticoagulation

Abstract Background Isolated splenic vein thrombosis (iSVT) is a common complication of pancreatic disease. Whilst patients remain asymptomatic, there is a risk of sinistral portal hypertension and subsequent bleeding from gastric varices if recanalization does not occur. There is a wide variation of iSVT treatment, even within single centres. We report outcomes of iSVT from tertiary referral hepatobiliary and pancreatic (HPB) units including the impact of anticoagulation on recanalization rates and subsequent variceal bleeding risk. Methods A retrospective cohort study including all patients diagnosed with iSVT on CT scan abdomen and pelvis between 2011 and 2019 from two institutions. Patients with both SVT and portal vein thrombosis at diagnosis, and isolated splenic vein thrombosis secondary to malignancy were excluded. The outcomes of anticoagulation, recanalization rates, risk of bleeding, and progression to portal vein thrombosis were examined. Results Ninety-eight patients with iSVT were included; of which thirty-nine patients received anticoagulation (40%). The most common cause of iSVT was acute pancreatitis n = 88 (90%). The recanalization rate in the anticoagulation group was 46% vs 15% in patients receiving no anticoagulation (p = 0.0008, OR = 4.7, 95% CI 1.775 to 11.72). Upper abdominal vascular collaterals (demonstrated on CT scan angiography) were significantly less among patients who received anticoagulation treatment (p = 0.03, OR = 0.4, 95% CI 0.1736 to 0.9288). The overall rate of upper GI variceal related bleeding was 3% (n = 3/98) and it was independent of anticoagulation treatment. Two of the patients received therapeutic anticoagulation. Conclusions The current data support that therapeutic anticoagulation is associated with a statistically significant increase in recanalization rates of the splenic vein; with a subsequent reduction in radiological left-sided portal hypertension. However, all patients had a very low risk of variceal bleeding regardless of anticoagulation. The findings from this retrospective study should merit further investigation in large-scale randomized clinical trials.

Bleeding and Thrombotic Events During Extracorporeal Membrane Oxygenation for Postcardiotomy Shock

BackgroundAnticoagulation therapy management during venoarterial extracorporeal membrane oxygenation (ECMO) is particularly difficult in postcardiotomy shock patients given a significant bleeding risk. We sought to determine the effect of anticoagulation treatment on bleeding and thrombosis risk for postcardiotomy shock patients on ECMO. MethodsWe retrospectively reviewed patients who received ECMO for postcardiotomy shock from July 2007 through July 2019. Characteristics of patients who had bleeding and thrombosis were investigated, and risk factors were assessed by multilevel logistic regression. ResultsOf the 152 patients who received ECMO for postcardiotomy shock, 33 (23%) had 40 thrombotic events and 64 (45%) had 86 bleeding events. Predictors of bleeding were intraoperative packed red blood cell transfusion (odds ratio [OR] 1.05; 95% confidence interval [CI], 1.01 to 1.09), platelet transfusion (OR 1.10; 95% CI, 1.05 to 1.16), international normalized ratio (OR 1.18; 95% CI, 1.02 to 1.37), and activated partial thromboplastin time greater than 60 seconds (OR 2.32; 95% CI, 1.14 to 4.73). Predictors of thrombosis were anticoagulant use (OR 0.39; 95% CI, 0.19 to 0.79), surgical venting (OR 3.07; 95% CI, 1.29 to 7.31), hemoglobin (OR 1.38; 95% CI, 1.06 to 1.79), and central cannulation (OR 2.06; 95% CI, 1.03 to 4.11). The daily predicted probability of thrombosis was between 0.075 and 0.038 for patients who did not receive anticoagulation and decreased to between 0.030 and 0.013 for patients who received anticoagulation treatment at activated partial thromboplastin times between 25 and 80 seconds. ConclusionsAnticoagulation therapy can reduce thromboembolic events in postcardiotomy shock patients on ECMO, but bleeding risk may outweigh this benefit at activated partial thromboplastin times greater than 60 seconds.

Treatment Patterns and Clinical Outcomes in Korean Cancer Patients With Venous Thromboembolism: A Retrospective Cohort Study.

This study assessed epidemiologic data and clinical outcomes, including venous thromboembolism (VTE) recurrence and bleeding events, in patients with cancer-associated VTE, and assessed factors associated with clinical outcomes. Data were extracted from retrospective medical-chart review of adult patients diagnosed with cancer-associated deep vein thrombosis or pulmonary embolism who received anticoagulation treatment for ≥3 months. Patients were classified by: low-molecular-weight heparin (LMWH), direct oral anticoagulants (DOACs), and other anticoagulants. First VTE recurrence and bleeding events, and factors associated with their occurrence, were assessed during the initial 6 months of treatment. Overall, 623 patients (age: 63.7 ± 11.3 years, 49.3% male) were included (119, 132, and 372 patients in LMWH, DOACs and other anticoagulants groups, respectively). The cumulative 6-month incidence of VTE recurrence was 16.6% (total), 8.3% (LMWH), 16.7% (DOACs), and 20.7% (other); respective bleeding events were 22.5%, 11.0%, 12.3%, and 30.7%). VTE recurrence and bleeding rates differed only between LMWH and other anticoagulants (HR 2.4, 95% CI: 1.2-5.0 and 3.6, 1.9-6.8, respectively). These results highlight the importance of initial VTE treatment choice for preventing VTE recurrence and bleeding events. LMWH or DOACs for ≥3 months can be considered for effective VTE management in cancer patients.

Superior ophthalmic vein thrombosis post manual carotid compression for indirect carotid-cavernous fistula

ABSTRACT Purpose To report 5 cases of superior ophthalmic vein thrombosis (SOVT) following intermittent manual carotid compression (IMCC) for indirect carotid-cavernous fistula (CCF) and to outline the management. Methods Retrospective observational case series of all patients who developed SOVT secondary to IMCC for indirect low flow CCF’s at a tertiary care center. The demographic profile, clinical, imaging findings, treatment, and outcomes were studied. Results The mean age at presentation was 60.2 years (Range: 42–87 years). Four patients were male. All patients had a unilateral presentation. The mean time interval between starting IMCC and the development of SOVT was 1.18 months (Range: 0.25–3 months). Acute exacerbation of proptosis and chemosis associated with a decrease in vision was the presenting feature in all the patients. The mean visual acuity at presentation was 0.89 on the logMAR scale. The causes of reduced visual acuity were venous stasis retinopathy (n = 4) and compressive optic neuropathy (n = 1). Magnetic resonance imaging revealed enlarged superior ophthalmic vein with absent flow voids and post-contrast filling defects. Four patients received anticoagulation treatment with subcutaneous injection of enoxaparin 1 mg/kg twice daily for 5 days followed by oral warfarin 5 mg once daily along with oral steroids. Complete recovery of SOVT was noted in all patients at a mean duration of treatment of 0. 75 months (Range: 0–2 months). Conclusion SOVT is a rare but possible complication in patients on IMCC for indirect CCF, and hence warrants close follow up. Early diagnosis and prompt management will help in preventing complications like permanent vision loss.

Cervical Spine Decompression and Fusion Outcomes in Trauma Patients Actively Receiving Anticoagulation Treatment for Cerebrovascular Injury: A Retrospective Comparative Study.

Cervical spine blunt trauma patients with the presence of a cerebrovascular injury may be given initiation of heparin anticoagulation treatment prior to necessary surgical stabilization. Literature regarding the safety and efficacy of these procedures while a patient is on active anticoagulation is limited, requiring further investigation. The primary research question for this study is: Can cervical spine decompression and fusion in the context of a blunt cerebrovascular injury and anticoagulation therapy be completed safely? To accomplish this a comparison of outcomes and perioperative complications was made to a control group. A total of 63 trauma patients requiring cervical spine decompression and fusion from 2013 to 2015 were identified at our North American level 1 trauma center. Evaluation of patient injury data, bleeding events, postoperative infections, and neurologic outcomes was collected from chart review. The American Spinal Injury Association (ASIA) grading system was used to measure change in postoperative neurologic outcomes. Of 63 patients, 14 had a concomitant cerebrovascular injury that required perioperative anticoagulation treatment. In the 14 patients receiving anticoagulation, 11 had anterior and 3 had posterior stabilization. A total of 2 patients experienced a complication (pneumonia and hardware failure), but neither was related to anticoagulation. An elevated prothrombin time value was noted postoperatively in 1 patient, but with no adverse outcome. No bleeding or thrombotic events, surgical site infection, or neurologic deterioration occurred. The difference in postoperative ASIA grades between groups was not significantly different (P = .57). The operative cohort receiving anticoagulation therapy did not demonstrate an increase affinity for perioperative complications or a decline in ASIA scores postoperatively when compared to a control cohort. Patients with a cerebrovascular injury receiving anticoagulation treatment can undergo safe and successful cervical spine stabilization procedures. Therapeutic level III.

Perioperative Deep Vein Thrombosis in Patients With Lower Extremity Fractures: An Observational Study.

This study aimed to investigate deep vein thrombosis (DVT) in patients with lower extremity fractures who received anticoagulation treatment in the perioperative stage. We collected the patients’ clinical data and diagnosed DVT using Doppler ultrasonography. Preoperative, postoperative, and 1-month postoperative examinations were performed. The patients were divided into thrombosis and non-thrombosis groups according to ultrasonographic findings. A total of 404 patients were included in the study. The preoperative, postoperative, and 1-month postoperative incidence rates were, respectively, 35%, 55%, and 40% for DVT and 12%, 22%, and 20% for DVT in the uninjured contralateral lower extremity. The incidence of perioperative DVT decreased over time from 223 (55%) to 161 (40%). Multivariate analysis revealed that the independent risk factors for preoperative that of DVT were age (odds ratio [OR]: 1.03; 95% CI: 1.01-1.04; P = .000); postoperative that of DVT were age (OR: 1.04; 95% CI: 1.03-1.05; P = .000), blood loss (OR: 1.001; 95% CI: 1.000-1.002; P = .018), and American Society of Anesthesiologists classification (OR: 2.07; 95% CI: 1.16-3.72; P = .014); and 1-month postoperative that of DVT were age (OR: 1.05; 95% CI: 1.03-1.07; P = .000), respectively. In conclusion, the incidence of perioperative DVT decreased over time in patients who received anticoagulation treatment. Age was an important risk factor for perioperative DVT.

Subcutaneous Injection of Tranexamic Acid to Reduce Bleeding During Dermatologic Surgery: A Double-Blind, Placebo-Controlled, Randomized Clinical Trial.

Topical application, oral, and IV injection of tranexamic acid (TXA) have been used to reduce surgical bleeding. To evaluate the safety and efficacy of TXA injected subcutaneously to reduce bleeding during dermatologic surgery. In this double-blinded, placebo-controlled, randomized prospective study, 131 patients were randomized to subcutaneous injection of lidocaine 2% diluted 1:1 with either saline (placebo) or TXA 100 mg/1 mL before surgery. Before the second stage or closure, size measurements of bloodstain impregnation on Telfa and surgical wound size were recorded and analyzed using mixed-effects linear regression. Subjective evaluation of hemostasis was performed using 4-point scale grading and analyzed using Fischer's exact test. One hundred twenty-seven patients completed the study. The bloodstain to surgical wound size ratio was smaller in the TXA group (1.77) compared with the placebo group (2.49) (p < .001). An improved effect of TXA on bleeding was observed in the subgroup of patients receiving anticoagulants (mean difference; 95% confidence interval; -0.83; -1.20 to -0.46 p < .001). The subjective hemostasis assessment was significantly better in the TXA group overall (p = .043) and anticoagulant subgroup (p = .001) compared with the placebo group. Subcutaneous injection of TXA was safe, reduced bleeding during dermatologic surgery, and particularly effective for patients receiving anticoagulation treatment.

Renal Infarction and Its Consequences for Renal Function in Patients With Cardiac Amyloidosis

ObjectiveTo describe the prevalence of and risk factors for renal infarction (RI) in patients with cardiac amyloidosis. Patients and MethodsWe evaluated 87 patients with cardiac amyloidosis who underwent renal technetium-99m-labeled dimercaptosuccinic acid scintigraphy in the Amyloidosis Referral Center of Henri-Mondor Hospital from October 1, 2015, through February 28, 2018. ResultsThree groups of patients were identified according to the underlying amyloidosis disorder: AL amyloidosis in 24 patients, mutated-transthyretin amyloidosis in 24 patients, and wild-type transthyretin amyloidosis in 39 patients. Patients with wild-type transthyretin amyloidosis were older (P<.001), more likely to be men (P=.02), to have arrhythmic heart diseases (P<.001), and to be receiving anticoagulation treatment (P<.001). Patients with AL amyloidosis had significantly higher N-terminal pro-B-type natriuretic peptide levels (P=.02) and were more likely to have nephrotic syndrome (P<.001). Renal infarction was detected in 18 patients (20.7%), at similar frequencies in the various groups. Baseline urinary protein to creatinine ratio was the only parameter for which a significant difference (P=.03) was found between patients with and without RI diagnoses. The likelihood of RI diagnosis was 47.1% (8 of 17) in the presence of AKI and 14.5% (10 of 69) in its absence (P=.003). Overall, heart transplant–censored patient survival did not differ significantly between patients with and without RI (P=.64), but death- and heart transplant–censored renal survival was significantly lower in patients with RI (P<.001). ConclusionOur study suggests that prevalence of RI in patients with cardiac amyloidosis is higher than previously thought, regardless of the underlying amyloidosis disorder. Acute kidney injury in a patient with cardiac amyloidosis should alert clinicians to the possibility of RI.

Decrease of Asparaginase Induced Thrombotic Events with Antithrombin III Monitoring and Repletion

IntroductionAsparaginase is incorporated into many multi-agent chemotherapy regimens used in the treatment of acute lymphoblastic leukemia (ALL). Asparaginase depletes proteins including stores of factors in the coagulation cascade and proteins regulating it, including antithrombin III (AT) and fibrinogen. This results in an increased risk of both bleeding and thrombosis. The rate of thrombosis following administration of asparaginase ranges from 5% to 35%, depending on treatment protocol and study design. While recommendations exist for the repletion of coagulation factors with cryoprecipitate and fresh frozen plasma (FFP), there are no current consensus recommendations for the replacement of AT in patients receiving asparaginase. This study aims to assess if administration of AT replacement products decreased the risk of thrombosis in ALL, lymphoblastic lymphoma, and NK/T-cell lymphoma patients with asparaginase-induced deficiency. Secondarily, this study investigated the risk of hemorrhage, budgetary impact of AT replacement products, and survival in this patient population.MethodsThis retrospective study evaluated patients 18 years of age or older who received L-asparaginase, pegaspargase, or asparaginase Erwinia chrysanthemi between January 2011 and June 2018 for ALL, lymphoblastic lymphoma, or NK/T-cell lymphoma. At our institution, a change in practice occurred in 2014 which led to the monitoring and supplementation of AT in this patient population. AT levels were monitored in patients post asparaginase therapy and supplementation was provided when levels were below 60%. Patients receiving anticoagulation treatment prior to the start of asparaginase therapy were excluded from the study. Data were analyzed using Chi-squared and T-tests were used to assess for significance between the groups.ResultsForty-six patients were analyzed in total; the mean age was 36 years of age and the most common diagnoses were B-cell ALL and T-cell ALL; 26 patients did not receive AT monitoring while 20 patients were monitored and received AT repletion (Table 1). There was a statistically significant difference in the development of thrombi between the groups with only 2 patients (10%) in the treatment group developing a thrombus compared to 10 patients (38%) in the non-treatment group (p=0.029) (Table 2). Two patients in the non-treatment group developed a sinus venous thrombus. It should be noted, a patient in each group developed multiple thrombi (Table 3). Overall, no patients experienced a clinically significant bleeding event that required clinical intervention. Overall survival was similar between groups with death from any cause occurring in 5 patients (25%) in the treatment group and 8 patients (31%) in the non-treatment group (p=0.67) (Table 2). The average cost of AT replacement for patients receiving supplementation was $78,370.ConclusionThe monitoring and supplementation of AT in ALL, lymphoblastic lymphoma, and NK/T-cell lymphoma patients was associated with a significant decrease in the occurrence of clinically significant thrombi. Patients in both groups did not experience bleeding events and the overall survival rate was similar between groups. While the average cost of AT repletion was considerable, the cost associated with a thrombus is arguably more substantial when taking into account intensive care admissions, diagnostic exams, and anticoagulation medications. Therefore, the result of this study suggests utilization of monitoring AT activity and its supplementation in patients receiving asparaginase therapy. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.