Significant Difference In Bleeding Complications Research Articles

Increased anti-thrombotic therapy is associated with decreased major adverse limb events in patients with low wound and foot infection scores.

The optimal anti-thrombotic management of patients after lower extremity bypass has yet to be fully elucidated, in part due to significant heterogeneity in patient presentation and practice patterns. The Wound, Ischemia, and foot Infection (WIfI) score is a validated scoring system to assist in the management of patients with chronic limb threatening ischemia (CLTI). We hypothesized that performing a restriction analysis based on WIFI scores would assist in the postoperative anti-thrombotic management of patients undergoing infrainguinal bypass. A retrospective cohort of infrainguinal bypass procedures completed at a single hospital system between January 2018 and January 2021 was selected, and preoperative WIfI scores were extracted for each patient. Patients with either Wound scores of 2 and 3, or Ischemia Scores of 0 and 1, or Foot Infection Scores of 3 were excluded. Based on the type of anti-thrombotic regimen on discharge, demographics, comorbidities, type of bypass, 30-day rates of graft occlusion, major amputation, mortality, and major adverse limb events (MALE) were analyzed. Statistical analysis included t-tests, chi square tests, and time-to-event survival analysis. 230 procedures were included in the study. 69 (30.0%) patients were discharged on single antiplatelet therapy (SAPT), compared to 161 (70.0%) who were discharged on either dual antiplatelet therapy or anticoagulation (DAPT/AC). There was a higher prevalence of bypasses using prosthetic conduit in the DAPT/AC group (45.9 vs 31.8%, p = .047); no other demographic or procedural variable analyzed had any significant differences. At 30-days postoperatively, there was no significant difference in postoperative reintervention rates, however, the DAPT/AC group had significantly lower rates of mortality (1.2 vs 7.2%, p = .01), major amputation (1.2% vs 5.8%, p = .04), and MALE (3.7 vs 13.0%, p < .01). There were no significant differences in bleeding complications. Survival analysis demonstrated that MALE-free survival was higher in the DAPT/AC group compared to the SAPT group (p < .01). On Cox regression analysis, DAPT/AC was associated with significantly decreased rates of MALE + mortality (Hazard Ratio (HR) 0.20 [0.06 - 0.66]). Lower extremity bypasses patients with low Wound and low foot Infection scores who are discharged on DAPT/AC postoperatively have a significantly higher 30-day MALE-free survival rate compared to patients discharged on SAPT; consideration could be made to preferentially discharge such post-bypass patients on DAPT/AC.

707 Comparing VTE Prophylaxis Strategies in Thermal Injuries: Don't Get Burned by Heparin!

Abstract Introduction Burn patients are at high risk of venous thromboembolism (VTE) as well as bleeding complications, thus choosing the best option for thromboprophylaxis can be challenging. Previous studies have analyzed the preferred antithrombotic agent in trauma patients, but this has not been established in burns. We hypothesize that low molecular weight heparin (LMWH) is associated with better outcomes than unfractionated heparin. Methods The Trauma Quality Improvement Project (TQIP) dataset was used to identify all patients with second- or third-degree burns that were administered VTE prophylaxis. Cases with missing data, &amp;lt; 24-hour hospital length of stay, other serious traumatic injuries (any AIS &amp;gt;3), interhospital transfer, history of kidney disease, or pre-hospital history of anticoagulant use were excluded. Bleeding complications were defined as hemorrhage control surgery, embolization procedures, or blood transfusion occurring after the initiation of thromboprophylaxis, consistent with other studies analyzing bleeding complications in TQIP. Rates of VTE and bleeding complications were compared between those who received heparin versus LMWH. Propensity score matching was performed to control for age, total body surface area percent (TBSA%) burned, and ICU admission (Table 1). Results The analysis included 9,857 patients (69% male). Median age was 50 (34-62) years. LWMH was associated with fewer complications including pulmonary embolism, any VTE, and bleeding (Table 2). Initiation of thromboprophylaxis within 24 hours of arrival was associated with a lower risk of VTE (1.0% vs 2.1%, p&amp;lt; 0.001) without showing a significant difference in bleeding complications (6.4% vs 7.2%, p=0.206). Conclusions This propensity score matched analysis of nearly ten thousand burn patients has demonstrated that low molecular weight heparin is associated with reduced risk of VTE and bleeding compared to heparin. Initiation of thromboprophylaxis within 24 hours is linked to lower rates of VTE. In burn patients without contraindications, thromboprophylaxis with LMWH should be started within 24 hours. Applicability of Research to Practice Venous thromboembolism is an important complication in burn patients, which may negatively impact patient outcomes. These patients regularly receive DVT prophylaxis and it is important for their care team to be able to select the proper agents.

Comparison of Efficacy of Biliverdin vs Heparin in Patients with Stable Ischemic Heart Disease Undergoing Percutaneous Coronary Intervention

Objective: To compare the efficacy and safety of biliverdin versus heparin in preventing thrombotic complications during percutaneous coronary intervention (PCI) in patients with stable ischemic heart disease. Methods: A total of 1000 patients were enrolled in the study, with 500 patients receiving biliverdin and 500 receiving heparin. The primary endpoint was the incidence of thrombotic complications during PCI, and the secondary endpoint was the incidence of bleeding complications. Results: Biliverdin was associated with a significantly lower incidence of thrombotic complications compared to heparin (5.6% versus 9.8%, respectively; p&lt;0.05). There was no significant difference in bleeding complications between the two groups (3.8% for biliverdin versus 3.2% for heparin; p=0.63). Logistic regression analysis found that biliverdin use was independently associated with a lower risk of thrombotic complications, even after adjusting for baseline demographic and clinical characteristics. Practical Implications: This study suggests that the use of biliverdin during percutaneous coronary intervention in patients with stable ischemic heart disease may provide a more effective alternative to heparin for preventing thrombotic complications without increasing the risk of bleeding complications. Conclusion: Biliverdin may be a more effective alternative to heparin for use during PCI in patients with stable ischemic heart disease, without increasing the risk of bleeding complications. Further studies are needed to confirm these findings and determine the long-term safety and efficacy of biliverdin in larger populations and over longer periods of follow-up. Keywords: Biliverdin, heparin, percutaneous coronary intervention, stable ischemic heart disease, thrombotic complications, bleeding complications.

Prophylactic platelet transfusion and risk of bleeding associated with ultrasound-guided central venous access in patients with severe thrombocytopenia.

Reported risk of bleeding complications after central catheter access in patients with thrombocytopenia is highly variable. Current guidelines recommend routine prophylactic platelet (PLT) transfusion before central venous catheter placement in patients with severe thrombocytopenia. Nevertheless, the strength of such recommendations is weak and supported by observational studies including few patients with very low PLT counts (<20 × 109 /L). This study aims to assess the risk of bleeding complications related to using or not using prophylactic PLT transfusion before ultrasound-guided central venous access in patients with very low PLT counts. This was a retrospective cohort study of patients with very low PLT counts (<20 × 109 /L) subjected to ultrasound-guided central venous catheterization between January 2011 and November 2019 in a university hospital. Bleeding complications were graded according to the Common Terminology Criteria for Adverse Events. A multivariate logistic regression was conducted to assess the risk of major and minor bleeding complications comparing patients who did or did not receive prophylactic PLT transfusion for the procedure. Multiple imputation by chained equations was used to handle missing data. A two-tailed p< 0.05 was considered statistically significant. Among 221 patients with very low PLT counts, 72 received prophylactic PLT transfusions while 149 did not. Baseline characteristics were similar between transfused and nontransfused patients. No major bleeding events were identified, while minor bleeding events were recognized in 35.7% of patients. Multivariate logistic regression analysis showed no significant differences in bleeding complications between patients who received prophylactic PLT transfusions and those who did not (odds ratio 0.83, 95% confidence interval 0.45-1.55, p= 0.567). Additional complete case and sensitivity analyses yielded results similar to those of the main analysis. In this single-center retrospective cohort study of ultrasound-guided central venous access in patients with very low PLT counts, no major bleeding was identified, and prophylactic PLT transfusions did not significantly decrease minor bleeding events.

Effect of Anticoagulant Versus Non-Anticoagulant Therapy on Mortality of Sepsis-Induced Disseminated Intravascular Coagulation: A Systematic Review and Meta-Analysis.

Sepsis is a syndrome of severe systemic inflammatory response. When combined with disseminated intravascular coagulation, mortality is increased. The need for anticoagulant therapy is still the focus of debate. PubMed, Embase, Cochrane Library, and Web of Science were searched. Adult patients with sepsis-induced disseminated intravascular coagulation were included in this study. All-cause mortality as efficacy and serious bleeding complications as adverse effect were measured as primary outcomes. Methodological quality of included studies were assessed using the Methodological Index for Non-randomized Studies (MINORS). Meta-analysis was performed using R software (version 3.5.1) and Review Manager (version 5.3.5). There were nine eligible studies with 17,968 patients included. There were no significant reductions in mortality between the anticoagulant group and the non-anticoagulant group (RR, 0.89; 95% CI, 0.72-1.10; P = 0.27). The DIC resolution rate in the anticoagulation group has a statistically significant increase compared with the control group [OR: 2.62, 95% CI (1.54-4.45), P < 0.05]. And there was no significant difference in bleeding complications between the two groups (RR, 1.27; 95% CI, 0.77-2.09; P = 0.69). SOFA score reduction did not change significantly between the two groups (P = 0.13). Our study observed no significant benefit of anticoagulant therapy on mortality of sepsis-induced DIC. Anticoagulation therapy can promote DIC resolution in sepsis-induced DIC. In addition, anticoagulant therapy does not increase the risk of bleeding in these patients.

Can we lower the platelet threshold of ≥ 50 × 109/L for performing a lumbar puncture safely in patients with hematological malignancies?

Lumbar punctures (LP) are routinely used to administer intrathecal chemotherapy for children and adults with hematologic malignancies. The current guidelines suggest a platelet threshold of ≥ 50 × 109/L prior to LP for intrathecal chemotherapy (ITC). This can be challenging in patients with hematological malignancies who are thrombocytopenic. We conducted a retrospective chart review of 900 LPs for ITC and compared adverse events in patients with a platelet count of ≥ 50 × 109/L and < 50 × 109/L. Cohort 1 included 682 LPs (75.8%) with a pre-procedure platelet count ≥ 50 × 109/L, and cohort 2 included 218 LPs (24.2%) with a pre-procedure platelet count < 50 × 109/L. Cohort 2 was further subdivided into pre-procedure platelet counts of 41 × 109/L-49 × 109/L (n = 43), 31 × 109/L-40 × 109/L (n = 77), 21 × 109/L-30 × 109/L (n = 84), and 11 × 109/L-20 × 109/L (n = 14). Among 900 LP procedures, a pre-procedure platelet count < 50 × 109/L did not demonstrate a higher rate of post-procedure adverse events (6.5% vs 6.8%, p = 0.8237). When cohort 2 was further stratified, the cohort with a pre-procedure platelet count of 21 × 109/L-30 × 109/L had the highest percentage of complications from LP (9.5%) and the highest rates of traumatic taps with observed LP RBC count > 200 (35.7%, p = 0.0015). The rate of red blood cells (RBC) in the CSF was significantly higher in the group with platelets < 50 × 109/L with observed LP RBC count ≥ 200 (31.2% vs 20.5%, p = 0.0016), ≥ 500 (27.1% vs 14.6%, p < 0.0001), and ≥ 1000 (23% vs 11.6%, p < 0.0001). No instances of epidural hematomas were seen. We found no significant difference in bleeding complications between patients undergoing LPs for ITC with a platelet count above or below 50 × 109/L.

The efficacy and cost-effectiveness of enoxaparin versus rivaroxaban in the prevention of venous thromboembolism following total hip or knee arthroplasty: A meta-analysis

IntroductionThromboprophylaxis following total hip and knee arthroplasty is variable across institutions, but commonly consists of enoxaparin, and more recently rivaroxaban. We aimed to analyze the current evidence on the efficacy, safety and cost-effectiveness of rivaroxaban versus enoxaparin for thromboprophylaxis following TKA or THA. MethodsThis study was conducted according to PRISMA guidelines. Electronic database searches were performed using three databases from their dates of inception to June 2020. Relevant randomized controlled studies were identified, with data extracted and analyzed. ResultsFrom eight studies, 13,384 patients were included, with 5700 undergoing TKA and 7684 undergoing THA. There were 6629 patients receiving rivaroxaban and 6755 patients receiving enoxaparin. From the total cohort, rivaroxaban was associated with significantly lower rates of major VTE (p = 0.009) and DVT (p < 0.001) when compared to enoxaparin. There was no significant difference in bleeding complications between rivaroxaban and enoxaparin groups (p = 0.14). Subgroup analysis of patients undergoing THA demonstrated that rivaroxaban reduced risk of major VTE (p = 0.002) and DVT (p = 0.01) with no significant differences in any other complications. For those undergoing TKA, rivaroxaban significantly reduced the risk of DVT (p < 0.001) but was associated with higher rates of post-operative blood transfusion (p = 0.03). Cost-analysis revealed that rivaroxaban was superior to enoxaparin, with the medication cost needed to prevent one DVT being $1081 and $432 less with rivaroxaban for THA and TKA respectively ConclusionsRivaroxaban may be a safe and cost-effective alternative to enoxaparin for routine thromboprophylaxis following total knee or hip arthroplasty.

Adjunctive Catheter-Directed Thrombolysis during Primary PCI for ST-Segment Elevation Myocardial Infarction with High Thrombus Burden.

Background: High coronary thrombus burden has been associated with unfavorable outcomes in patients with ST-segment elevation myocardial infarction (STEMI), the optimal management of which has not yet been established. Methods: We assessed the adjunctive catheter-directed thrombolysis (CDT) during primary percutaneous coronary intervention (PCI) in patients with STEMI and high thrombus burden. CDT was defined as intracoronary infusion of tissue plasminogen activator (t-PA; monteplase). Results: Among the 1849 consecutive patients with STEMI, 263 had high thrombus burden. Moreover, 41 patients received t-PA (CDT group), whereas 222 did not receive it (non-CDT group). No significant differences in bleeding complications and in-hospital and long-term mortalities were observed (9.8% vs. 7.2%, p = 0.53; 7.3% vs. 2.3%, p = 0.11; and 12.6% vs. 17.5%, p = 0.84, CDT vs. non-CDT). In patients who underwent antecedent aspiration thrombectomy during PCI (75.6% CDT group and 87.4% non-CDT group), thrombolysis in myocardial infarction grade 2 or 3 flow rate after thrombectomy was significantly lower in the CDT group than in the non-CDT group (32.2% vs. 61.0%, p < 0.01). However, the final rates improved without significant difference (90.3% vs. 97.4%, p = 0.14). Conclusions: Adjunctive CDT appears to be tolerated and feasible for high thrombus burden. Particularly, it may be an option in cases with failed aspiration thrombectomy.

Abstract 13101: Bleeding Complications in Patients Undergoing Percutaneous Coronary Intervention With Intra-Aortic Balloon Pump and/or Impella Support: A System Wide Analysis

Background: Mechanical circulatory support (MCS) devices are used to provide temporary hemodynamic support in patients undergoing percutaneous coronary interventions (PCI). Currently, the most used percutaneous devices are the intra-aortic balloon pump (IABP) and the Impella micro-axial flow device. Aim: To assess bleeding complications associated with IABP and/or Impella in patients undergoing PCI. Methods: Between 12/2010 and 03/2018 a total of 883 patient underwent PCI with MCS at 6 hospitals in our system. Patients were divided into three groups: IABP (n=679), Impella (n=171) and IABP with Impella (n=33). Bleeding complications were classified according to the Bleeding Academic Research Consortium (BARC). BARC Type 4 (coronary bypass grafting-related) and BARC Type 5 (fatal bleeding) bleeding events were excluded. Chi-square tests and logistic regression were utilized with p&lt;0.05 significance level. Multiple pairwise comparisons using Bonferroni-adjusted p-value threshold of p&lt;0.0167 for level of significance was also performed. A multiple variable analysis will be presented. Results: Clinical characteristics, bleeding complications and in-hospital outcomes are shown in the Table. There were significant differences in these variables except age and gender among the three groups. A minority of patients (4%) were treated simultaneously with both devices, however 45% of these patients had a significant bleeding event and 33% died in the hospital. No significant difference in bleeding complications between IABP and Impella (each alone) was found (p=0.38). Conclusions: In patients undergoing PCI, use of a combination of IABP and Impella was associated with significantly higher rate of intermediate or major bleeding complications when compared with patients treated with either device alone. Furthermore, these patients had significantly higher in-hospital mortality rates.

The risks and benefits of early venous thromboembolism prophylaxis after elective spinal surgery: A single-centre experience.

There is a wide ranging incidence of venous thromboembolism after surgery and it continues to be a major cause of morbidity after spinal procedures.This study's aim was to investigate the relationship between timing and administration of venous thromboembolism (VTE) pharmacologic chemoprophylaxis after spinal surgery and the resulting VTE and bleeding complications by reviewing current practices and outcomes at a high-volume single institution to better define opportunities for perioperative intervention to prevent VTE without increasing bleeding complications. All patients who underwent elective one or two-stage lumbar spinal fusion procedures were identified. A logistic regression was used to evaluate (1) risk of symptomatic VTE within 30 days of surgery and (2) bleeding-related complications. The odds of developing a VTE as well as bleeding-related complications were compared among the three treatment groups: no chemoprophylaxis, chemoprophylaxis < 24h of surgery and chemoprophylaxis given > 24h post-surgery. When adjusted for doses administered, the odds of developing a postoperative VTE within 30 days were 0.189 (95% confidence interval (0.044, 0.808)) in patients who received anticoagulation < 24h postoperatively, compared to those who received no anticoagulation (p = 0.025). There was no difference in bleeding rates. Patients undergoing elective spinal surgery who received anticoagulation within 24h of the conclusion of their procedure had an 81% reduction in the odds of developing a deep vein thrombosis within 30 days with no significant difference in bleeding complications.

Bleeding Complications in CAT Patients Treated with LMWH or DOACs

BackgroundBleeding complications would occur more frequently among patients with a diagnosis of cancer during anticoagulant treatment than those without cancer. Recently, several new direct oral anticoagulants (DOACs) have become available for the treatment of VTE. However, only small portion of patients in the prospective trials had active cancer. Further there are not enough studies on bleeding events of patients with cancer associated thrombosis (CAT). We therefore conducted retrospective analysis of bleeding events in patients treated with LMWH and DOACs for CAT.MethodsWe reviewed medical records and gathered clinical data for patients diagnosed with CAT and treated with LMWH or DOACs between 2010 and 2015. Data included patient demographics and bleeding events.ResultsWe enrolled 606 patients from 7 hospitals in Korea for CAT in this retrospective analysis. Four hundred and seventy seven patients (78.7%) were treated with LMWH for anticoagulation of CAT while 129 patients (21.3%) were DOACs. Bleeding events occurred in 59 patients in the LMWH group and 31 patients in the DOACs group. Major bleeding events occurred in 13 patients in LMWH and 5 patients in DOACs. The cumulative incidence of major bleeding was 6.7% and 5% in DOACs, respectively. The Cumulative incidence of clinically relevant non-major (CRNM) bleeding events was 14.5% in LMWH and 16.4% in DOACs.ConclusionThere was no significant difference in bleeding complications when LMWH and DOACs were used in treatment of CAT in the real world. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Peripheral Extracorporeal Membrane Oxygenation is a safe and effective support modality for pediatric patients with sepsis

Background &#x0D; Extracorporeal Membrane Oxygenation (ECMO) can be used as a treatment modality for pediatric patients with refractory septic shock. Previous studies indicate central ECMO, with direct cardiac cannulation, is superior for septic patients. At Riley Hospital for Children, we believe that peripheral ECMO support, through cervical or femoral vessels, is an effective and safe method of supporting pediatric septic patients in a less invasive manner. &#x0D; &#x0D; Methods &#x0D; We reviewed pediatric (30 days to 18 years) patients supported with ECMO for septic shock from 2005-2019 at Riley Hospital for Children and compared them to non-septic respiratory failure patients supported with ECMO. Pre-ECMO data points, demographics, cannulation sites, flow rates, lab values, Vasoactive Ionotropic Score(VIS), P-Prep score, and outcomes were collected and analyzed using t-test and multivariate analyses. We defined a significance as p=0.05. &#x0D; Results &#x0D; 35 of 80 ECMO patients were supported for septic shock. Septic patients were larger (25.1kg vs 11.4kg, p=0.005) and older (85.6 vs 18.8 months, p=0.001). Pre-ECMO VIS and P-Prep were both greater in the septic group (p=0.007 and p&lt;0.001). Pre-ECMO serum lactate level was higher in the septic group (3.7 vs 1.4, p=0.012) , but by 96hrs, lactate normalized in both groups. Flow rates at 24 hours were similar between the two groups (91mL/kg/min vs 88mL/kg/min, p=0.079). No significant difference in bleeding complications or blood product administration was found, but there was a higher incidence of renal failure in septic patients. Survival in the septic group was similar to the comparison group (51.4% vs 62.2%, p-0.37). Hours on ECMO and length of stay were also similar. &#x0D; Conclusion and Potential Impact &#x0D; Despite septic patients appearing more ill prior to ECMO, they had similar mortality, support parameters, and outcomes, showing that septic shock is not a contraindication to peripheral ECMO support in pediatric patients.

Risks and complications of robot-assisted radical prostatectomy (RARP) in patients receiving antiplatelet and/or anticoagulant therapy: a retrospective cohort study in a single institute

The objective of the study was to evaluate the risk of bleeding complications in patients undergoing robot-assisted radical prostatectomy (RARP) while taking antiplatelet (AP) and/or anticoagulant (AC) agents. We analyzed the data of 334 patients undergoing RARP from May 2015 to May 2019. Patients were categorized into AP, AC, and control groups; the bleeding complications were compared among them. The end points were the estimated blood loss, decrease in hemoglobin level, and bleeding complications. The patient characteristics did not differ significantly among groups, with the exception of ASA scores, which were significantly higher in the AP and AC groups vs. the control group. The estimated blood loss and hemoglobin decrease were not significantly different between the AP and AC groups and the control group. The frequency of bleeding complications did not differ significantly between the AP and the control groups, but was significantly higher in the AC vs. the control group (4.3% in the AP and 23.5% in the AC group vs. 3.7% in the control group; P = 0.63 and P < 0.01, respectively). There was no significant difference in bleeding complications between the AP continuation (continuation of a single AP) and the AP interruption group or between the heparin bridging and the AC interruption group. All bleeding complications observed in the AC group occurred after resuming AC therapy. RARP can be performed safely with continuation of a single AP, and in patients taking ACs by interrupting these agents or via heparin bridging, without increasing intraoperative bleeding, whereas postoperative bleeding complications may increase after resuming ACs.

Safety and efficacy study of prourokinase injection during primary percutaneous coronary intervention in acute ST-segment elevation myocardial infarction.

ObjectivesTo evaluate the efficacy and safety of intracoronary administration of prourokinase via balloon catheter during primary percutaneous coronary interventions in patients with acute ST-segment elevation myocardial infarction.MethodsAcute ST-segment elevation myocardial infarction patients underwent primary percutaneous coronary interventions were randomly divided into two groups: intracoronary prourokinase group (n = 125) and control group (n = 135). During primary percutaneous coronary interventions, prourokinase or saline was injected to the distal end of the culprit lesion via balloon catheter after balloon catheter dilatation. Demographic and clinical characteristics, infarct size, myocardial reperfusion, and cardiac functions were evaluated and compared between two groups. Hemorrhagic complications and major averse cardiovascular events (MACE) occurred in the 6-months follow-up were recorded.ResultsNo significant differences were observed between two groups with respect to baseline demographic, clinical, and thrombolysis in myocardial infarction grade (P > 0.05). In the intracoronary prourokinase group, more patients had ST-segment resolution (>50%) compared with control group (P < 0.05). Patients in the intracoronary prourokinase group showed lower levels of serum CK, creatine kinase-MB fraction, and troponin I than those in control group (P < 0.05). No significant differences in bleeding complications were observed between the two groups (P > 0.05). At 6-months follow-up, there was no statistically different of MACE between the two groups (P > 0.05).ConclusionsIntracoronary administration of prourokinase via balloon catheter during primary percutaneous coronary interventions effectively improved myocardial perfusion and no increased bleeding in ST-segment elevation myocardial infarction patients.

MP32-14 CONTINUATION OF ANTIPLATELET AND/OR ANTICOAGULATION IN PATIENTS UNDERGOING REZūM PROSTATE ABLATION

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology II (MP32)1 Apr 2020MP32-14 CONTINUATION OF ANTIPLATELET AND/OR ANTICOAGULATION IN PATIENTS UNDERGOING REZūM PROSTATE ABLATION Ajay Gopalakrishna*, Raevti Bole, Ruby Kuang, David Yang, Matthew Houlihan, Masaya Jimbo, Sevann Helo, Matthew Ziegelmann, and Tobias Kohler Ajay Gopalakrishna*Ajay Gopalakrishna* More articles by this author , Raevti BoleRaevti Bole More articles by this author , Ruby KuangRuby Kuang More articles by this author , David YangDavid Yang More articles by this author , Matthew HoulihanMatthew Houlihan More articles by this author , Masaya JimboMasaya Jimbo More articles by this author , Sevann HeloSevann Helo More articles by this author , Matthew ZiegelmannMatthew Ziegelmann More articles by this author , and Tobias KohlerTobias Kohler More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000876.014AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Rezūm is a minimally invasive technique to treat benign prostatic hyperplasia (BPH). Major advantages include no de novo erectile dysfunction and low rate of retrograde ejaculation. Discontinuation of peri-operative antiplatelet and/or anticoagulation (APAC) is often preferred in practice to avoid bleeding complications. The objective of this study is to examine outcomes and complications in patients undergoing Rezūm on APAC. METHODS: We retrospectively reviewed patients who underwent Rezūm therapy at our institution since 7/2017. When deemed medically necessary, APAC was continued in the perioperative setting. Post-procedure catheterization regimen included a minimum of 3 days and a maximum of 4 weeks in men with preoperative catheter dependence. Outcomes included pre- and post-operative AUA symptoms score, peak flow, and postvoid residual. Bleeding-related complications and urinary tract infection rate were recorded. RESULTS: Of 214 patients who underwent Rezūm therapy, 68 patients were treated on APAC. The average prostate gland size was 73 grams. Significant improvements were seen in AUA symptom score, peak flow, and post void residual (Table 1). Bleeding complications requiring intervention occurred in 6 (9.3%) patients, with all 6 undergoing catheter irrigation, 2 undergoing blood transfusion, and 1 undergoing cystoscopic clot evacuation. Interestingly, 9/146 (6.3%) patients who were not on APAC had hematuria requiring intervention. There were no statistically significant differences in bleeding complications. There was no de novo erectile dyfunction reported. CONCLUSIONS: In our experience, bleeding complications in patients undergoing Rezūm on APAC is uncommon. There were no apparent differences in complication rates between patients on APAC and those not on APAC. To the best of our knowledge, this is the largest study to examine outcomes and complications of Rezūm in patients on APAC. Rezūm appears to be a safe and efficacious treatment option in men continuing APAC who wish to preserve sexual function. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e490-e490 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ajay Gopalakrishna* More articles by this author Raevti Bole More articles by this author Ruby Kuang More articles by this author David Yang More articles by this author Matthew Houlihan More articles by this author Masaya Jimbo More articles by this author Sevann Helo More articles by this author Matthew Ziegelmann More articles by this author Tobias Kohler More articles by this author Expand All Advertisement PDF downloadLoading ...

Is Routine Preprocedural Bloodwork Needed for Elective Central Venous Access Device Removals in Children without Bleeding Dyscrasias?

To assess the utility of routine preprocedural bloodwork during elective removal of central venous access devices (CVADs) with respect to bleeding complications. Patients who underwent removal of a CVAD (tunneled central venous catheter [CVC] or port) by the interventional radiology service between January 2009 and December 2013 were retrospectively reviewed. Removals for infection or malfunction, without preprocedural bloodwork, with another concurrent procedure at the time of CVAD removal, or in patients with a bleeding dyscrasia were excluded. Peripherally inserted central catheter removals and temporary CVAD removals were also excluded. Routine preprocedural bloodwork included hemoglobin, platelet count, partial thromboplastin time, and International Normalized Ratio. Postprocedural complications were classified according to the Society of Interventional Radiology clinical practice guidelines. There were 802 CVAD removals in 777 patients (351 female, 426 male). Average patient age was 8.6 years (range, 5 wk to 19 y). In total, 246 permanent CVCs and 556 ports were removed. A total of 802 cases had preprocedural bloodwork. Of the 49 patients who had a bleeding complication after the procedure (6.1%; 49 of 802), 44 had normal findings on preprocedural bloodwork and 5 had abnormal findings. There was no statistically significant difference in bleeding complications between those with normal and abnormal bloodwork results (P= .7740). Routine bloodwork is not necessary before elective CVAD removal in children without a bleeding dyscrasia. Most children have normal findings on preprocedural bloodwork, and the incidence of postprocedural bleeding is low and not determined by bloodwork results.

A Review of Two Heparin Prophylaxes for Trauma.

Venous thromboembolism (VTE) prophylaxis has a significant impact on mortality and morbidity in trauma patients. This article reviews 9 published studies that investigate and compare low-dose unfractionated heparin (LDUH) with low-molecular-weight heparin (LMWH) for prophylaxis of VTE in the trauma patient population in terms of efficacy, safety, and cost. There is no difference between LDUH and LMWH for VTE prophylaxis. Four databases were utilized to find 9 relevant studies whose patient population was adult trauma patients: PubMed, CINAHL, EMBASE and Scopus. Two studies found statistically significant differences in deep venous thrombosis, and 3 found differences in pulmonary embolism between LDUH and LMWH. Only 1 study demonstrated a significant difference in bleeding complications between the 2 treatment regimens. Two statedthat using LDUH resulted in remarkable cost savings versus LMWH. The 9 studies all came to different conclusions. Contrary findings may have been affected by population variety, different dosing regimens, various applications of mechanical VTE prophylaxis, and/or different VTE-screening tools. All of the studies had major variances leading to conflicting results, which made this review unable to draw concrete conclusions. Limitations of each study, population variety, and disparity of dosing regimens made it difficult for this review to make recommendations for practice.

COMPARISON OF BLEEDING COMPLICATIONS BETWEEN TURP AND OPEN PROSTATECTOMY IN PATIENT WITH BPH

Objective: Benign prostatic hyperplasia (BPH) is the enlargement of prostate glands. Two commonly used methods of BPH surgery in Indonesia are transurethral resection of prostate (TURP) and open prostatectomy. International studies have shown both methods have bleeding complications, occurring in 7% in TURP and 22% in open prostatectomy. But, only few researches for bleeding during BPH surgery are done in Indonesia. This study aimed to analyze the difference in bleeding complications between TURP and open prostatectomy in Indonesia. Material &amp; Methods: An observational study with cross-sectional design, using consecutive sampling from medical records of patients above 21 years old with BPH who came to Poli Urologi Soetomo Hospital in 2015–2016 for TURP or open prostatectomy. Data were analyzed using Fischer and Mann-Whitney. Results: Information was obtained from 62 patients, TURP was done in 49 patients (79.03%) and 13 patients (26.53%) in which had bleeding complication. Open prostatectomy was done in 13 patients (20.97%) and 6 patients (46.15%) in which had bleeding complications. Fischer test showed no significant difference in bleeding complications between TURP and open prostatectomy in patients with BPH (p=0.192), including patients with urine retention (p=0.451), without urine retention (p=0.249), age below 70 (p=0.140) and above 70 (p=1). Mann-Whitney test showed significant difference in bleeding complications volume between TURP and open prostatectomy (p=0.012). Conclusion: There was no significant difference in bleeding complications between TURP and open prostatectomy in patients with BPH. But, between TURP and open prostatectomy significant difference in bleeding volume was found.

Comparison of Bleeding Complications between Transplenic versus Transhepatic Access of the Portal Venous System

PurposeTo evaluate the incidence of bleeding complications between transplenic (TS) and transhepatic (TH) access in portal venous interventions. Materials and MethodsRetrospective review of patients who underwent TS or TH access for portal venous system interventions from January 2000 to August 2017. Only procedures with clinical and laboratory follow-up were included (n = 148). Twenty-four TS procedures were performed in 22 patients, and 124 TH procedures were performed in 114 patients. The main indications were for angioplasty/stent, embolization of varices/shunt, or portal vein embolization, with no difference between the groups. Mean patient age and sex were not significantly different between the groups (P values .445 and .682, respectively). Mean follow up was 2.3 years (range 0.1–14.2). There was no significant difference between the international normalized ratio (P = .300) and platelets (P = .234) before the procedure between the 2 cohorts. ResultsTechnical success of vascular access and procedural success was achieved in 22/24 (91.6%) TS procedures and 120/124 (96.8%) TH procedures (P = .238). There was no significant difference in bleeding complications between the 2 groups (3/24 [12.5%] TS vs 10/124 [8.1%] TH; P = .44). There was no significant difference in major bleeding complications (SIR classification ≥ C; 1/24 [4.2%] TS vs 4/124 [3.2%] TH; P = .789).There was no significant difference in the hemoglobin before or after the procedure (g/dL), with average change −1.1 g/dL (range −3.4 to +1.0) in the TS group and 1.0 g/dL (range −4.5 to +1.9) in the TH group (P = .540). Finally, there was no significant difference in proportion of patients requiring blood transfusion after the procedure (P = .520), with 2 (8.3%) in the TS group requiring an average of 4 units (range 2–6) and 17 (13.7%) in the TH group requiring an average of 3.5 units (range 1–26). ConclusionsThese data suggest no significant difference in bleeding complications between TS and TH access for portal venous interventions.

Prestroke and Poststroke Antithrombotic Therapy in Patients With Atrial Fibrillation

Antithrombotic therapies are effective in both primary and secondary stroke prophylaxis in high-risk patients with atrial fibrillation (AF), but they are often underused in community practice. To examine prestroke and poststroke antithrombotic treatment patterns and long-term outcomes in patients with AF presenting with ischemic stroke. A retrospective cohort study of Danish patients with AF, with a prestroke CHA2DS2-VASc score of 1 or higher for men and 2 or higher for women, and presenting with ischemic stroke was conducted from January 1, 2004, to January 31, 2017. Data on hospital admission, prescription fillings, and vital status were assessed using several Danish nationwide registries. Patients who survived 100 days after discharge were divided into 3 groups according to poststroke antithrombotic therapy: oral anticoagulation (OAC) therapy, antiplatelet therapy alone, or no antithrombotic therapy. Long-term outcomes (thromboembolic events and bleeding complications) were examined using multivariable Cox regression analyses across the 3 groups. Among 30 626 patients with AF admitted with ischemic stroke, 11 139 patients (36.3%) received OAC therapy (44.3% female; median age, 79 years [interquartile range, 73-85 years]), 11 874 (38.8%) received antiplatelet therapy alone (55.0% female; median age, 82 years [interquartile range, 75-88 years]), and 7613 (24.9%) received no antithrombotic therapy before stroke (53.8% female; median age, 80 years [interquartile range, 71-86 years]). Following stroke, 31.3% of those receiving antiplatelet therapy alone and 43.7% of those receiving no antithrombotic therapy before stroke shifted to OAC therapy. Yet, 37.5% of patients with stroke did not receive OAC therapy following stroke. However, OAC treatment rates increased over time. During a maximum of 10 years of follow-up, 17.5%, 21.2%, and 21.5% experienced a new thromboembolic event and 72.7%, 86.4%, and 86.2% died among those treated with OAC therapy, antiplatelet therapy, or no antithrombotic therapy, respectively. Poststroke OAC therapy was associated with lower risk of recurrent thromboembolic events (adjusted hazard ratio, 0.81; 95% CI, 0.73-0.89) and no significant difference in bleeding complications (adjusted hazard ratio, 0.97; 95% CI, 0.86-1.10), compared with no poststroke antithrombotic therapy. In contrast, there were no significant differences for those treated with poststroke antiplatelet therapy and no antithrombotic therapy. Patients with AF receiving poststroke OAC therapy had lower risk of recurrent thromboembolic events. Our findings suggest a substantial opportunity for improving primary and secondary stroke prophylaxis in high-risk patients with AF.