Rate Of Successful Hemostasis Research Articles

Heparin reversal for coronary artery perforation

Abstract Background/Introduction In the management of coronary artery perforation (CAP) during percutaneous coronary intervention (PCI), heparin reversal can provide hemostatic effects but raises concerns about potential coronary thrombosis if an intracoronary artery guidewire or balloon is in place. Purpose We aimed to evaluate the safety and efficacy of heparin reversal during device insertion for CAP. We also aimed to determine the optimal target activated clotting time (ACT) to maintain when performing heparin reversal. Methods We analyzed cases of CAP which occurred during PCI procedures in a single center from January 2006 to October 2023. Patients were assigned to two groups according to whether they received heparin reversal with a device in place. The safety outcome was the periprocedural myocardial infarction (creatine kinase-MB >5 times the upper normal limit), and the efficacy outcome was successful hemostasis at the end of the procedures (complete absence of CAP on angiography). Results Among the 22,368 cases, 368 (1.6%) developed CAP, consisting of main vessels 45%, distal vessels 43%, and collateral vessels 12%. Heparin reversal with a device in place was implemented in 211 (57%) cases. Of these, 16 (7.6%) experienced coronary thrombosis. After adjusting covariates by the multivariable logistic regression model, heparin reversal with a device in place was significantly associated with a higher incidence of periprocedural myocardial infarction (11% vs 4.5%; adjusted OR: 3.11; 95% CI: 1.24–7.78; P = 0.015) and a higher rate of successful hemostasis (91% vs 73%; adjusted OR: 2.78; 95% CI: 1.27–6.09; P = 0.011). In the analysis of cases where minimum ACT value was available (n = 251), this value was significantly correlated with coronary thrombosis (r = −0.16, P = 0.012). When the cutoff values of minimum ACT were set at 200, 150, and 120 seconds as a binomial variable, the correlation coefficient was r = −0.08 (P = 0.158), r = −0.16 (P = 0.009), r = −0.20 (P = 0.001), respectively. Conclusions Heparin reversal after CAP with an intracoronary artery device in place was significantly associated with a higher incidence of periprocedural MI but also a higher rate of successful hemostasis. A minimum ACT value <150 seconds was significantly correlated with coronary thrombosis. These results propose a novel algorithm for CAP management strategies.Management algorithm for CAP

The efficacy of sclerotherapy as the initial treatment in patients with bleeding from Dieulafoy's lesion of the upper gastrointestinal tract.

Dieulafoy's lesion (DL) is a rare and important cause of acute nonvariceal upper gastrointestinal bleeding (ANVUGIB), however, there is a lack of clear guidelines focus on the endoscopic hemostasis treatment for DL. Sclerotherapy, as the ANVUGIB guideline recommended endoscopic hemostasis method, is widely used in clinical practice. The aim of this study is to investigate the efficacy of sclerotherapy as the initial treatment for Dieulafoy's lesion of the upper gastrointestinal tract (UDL). Patients with UDL who underwent the ANVUGIB standard endoscopic hemostasis between April 2007 and January 2023 were enrolled. The endoscopic therapy method was left to the discretion of the endoscopist. In total, 219 patients were finally obtained, with 74 (33.8%) receiving sclerotherapy and 145 (66.2%) receiving other standard endoscopic therapy. The rebleeding within 30days was significantly lower in the sclerotherapy group compared to the other standard group (5.8% vs. 16.8%, p = 0.047). There were no significant differences between the two groups in terms of successful hemostasis rate (93.2% vs. 94.5%, p = 0.713), median number of red blood cell transfusions (3.5 vs. 4.0 units, p = 0.257), median hospital stay (8.0 vs. 8.0days, p = 0.103), transferred to ICU rate (8.1% vs. 6.2%, p = 0.598), the need for embolization or surgery rate (12.2% vs. 9.7%, p = 0.567) and 30-day mortality (0 vs. 2.1%, p = 0.553). In addition, we found no difference in efficacy between sclerotherapy alone and combination (3.1% vs. 8.1%, p = 0.714). Further analysis revealed that thermocoagulation for hemostasis was associated with a higher rate of rebleeding (28.6% vs. 3.1%, p = 0.042) and longer hospital stay (11.5 vs. 7.5days, p = 0.005) compared to sclerotherapy alone. Sclerotherapy represents an effective endoscopic therapy for both alone and combined use in patients with upper gastrointestinal Dieulafoy's lesion. Therefore, sclerotherapy could be considered as initial treatment in patients with bleeding of UDL.

Efficacy of hemostatic gel for perioperative bleeding and prevention of delayed bleeding of cold snare polypectomy under anticoagulant.

A hemostatic gel, PuraStat (3-D Matrix, Tokyo, Japan), is used for various gastrointestinal hemostasis. In this study, we analyzed the efficacy of PuraStat for perioperative bleeding (POB) and prevention of delayed bleeding (DB) to colorectal cold snare polypectomy (CSP) with continuous anticoagulant. This was a single-center, retrospective study. Subjects were lesions of 2-9 mm under continuous anticoagulant from 2021 to 2023 and treated with PuraStat for POB. The definition of POB was bleeding which did not stop spontaneously by 1.0-1.5 min after resection and needed hemostasis. Successful hemostasis was defined as cessation of bleeding within 1.0-1.5 min after spraying PuraStat and the rate of it and risk factors of POB were analyzed. For comparison, cases receiving previous CSP without PuraStat were extracted from all cases with CSP (2018-2021), and POB and DB rate (DBR) were analyzed after propensity score matching. One hundred twenty-two lesions (91: direct oral anticoagulant (DOAC), 31: warfarin) with anticoagulant were analyzed and the rate of successful hemostasis with PuraStat was 92.6% (DOAC/warfarin: 93.4%/80.6%, P = 0.01). The rate of DB was 0.0%. Multivariate analysis showed that significant risk factors about unsuccessful hemostasis for POB with PuraStat were lesion size 8-9 mm (P < 0.01), warfarin (P = 0.01), and combination of antiplatelet (P = 0.01). Regarding the comparison about CSP with/without PuraStat, the clipping rate and DBR were 8.5%/94.9% (P < 0.01) and 0%/1.7% (P = 1.0). The effects of PuraStat for POB and DB in colorectal CSP with continuous anticoagulant were acceptable.

New Alternative? Self-Assembling Peptide in Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.

Gastrointestinal bleeding (GIB) is a common and potentially fatal condition with all-cause mortality ranging from 3 to 10%. Endoscopic therapy traditionally involves mechanical, thermal, and injection therapies. Recently, self-assembling peptide (SAP) has become increasingly available in the United States. When applied to an affected area, this gel forms an extracellular matrix-type structure allowing for hemostasis. This is the first systematic review and meta-analysis to assess the safety and efficacy of this modality in GIB. We performed a comprehensive literature search of major databases from inception to Nov 2022. The primary outcomes assessed were the success of hemostasis, rebleeding rates, and adverse events. The secondary outcomes assessed were successful hemostasis with monotherapy with SAP and combined therapy, which may include mechanical, injection, and thermal therapies. Pooled estimates were calculated using random-effects models with a 95% confidence interval (CI). The analysis included 7 studies with 427 patients. 34% of the patients were on anticoagulation or antiplatelet agents. SAP application was technically successful in all patients. The calculated pooled rate of successful hemostasis was 93.1% (95% confidence interval (CI) 84.7-97.0, I2 = 73.6), and rebleeding rates were 8.9% (95% CI 5.3-14.4, I2 = 55.8). The pooled rates of hemostasis with SAP monotherapy and combined therapy were similar. No adverse events were noted related to SAP. SAP appears to be a safe and effective treatment modality for patients with GIB. This modality provides an added advantage of improved visualization over the novel spray-based modalities. Further, prospective, or randomized controlled trials are needed to validate our findings.

Effectiveness and Safety of Dabigatran Reversal with Idarucizumab in the Taiwanese Population: A Comparison Based on Eligibility for Inclusion in Clinical Trials.

Background and Objectives: The effectiveness and safety of idarucizumab for the reversal of the effects of dabigatran have been proven. However, there remains a paucity of literature comprehensively investigating outcomes in real-world patients. This is especially true when comparing patients who were eligible for inclusion in the RE-VERSE AD trial with patients who were ineligible. As the prescription of dabigatran has become increasingly popular, the generalizability of the results to real-world populations has come into question due to the broad variability of real-world patients receiving dabigatran. Our study aimed to identify all patients who were prescribed idarucizumab and examined how effectiveness and safety varied among those patients who were eligible and ineligible for the trial. Materials and Methods: This retrospective cohort study analyzed the largest medical database in Taiwan. We enrolled all patients who were prescribed and received idarucizumab from when it became available in Taiwan up until May 2021. A Total of 32 patients were included and analyzed, and they were further divided into subgroups based on their eligibility for inclusion in the RE-VERSE AD trial. Multiple outcomes were evaluated, including successful hemostasis rate, complete reversal efficacy of idarucizumab, 90-day thromboembolic events, intra-hospital mortality, and adverse event rate. Results: In our study, we found that 34.4% of real-world cases of idarucizumab use were ineligible for the RE-VERSE AD trials. The eligible group had higher successful hemostasis rates (95.2% vs. 80%) and anticoagulant effect reversal rates compared to the ineligible group (73.3% vs. 0%). The mortality rates were 9.5%, compared to 27.3% in the ineligible group. Few adverse effects (n = 3) and 90-day thromboembolic events (n = 1) were observed in either group. Among the ineligible cases, all acute ischemic stroke patients (n = 5) received definite, timely treatments without complications. Conclusions: Our study demonstrated the real-world effectiveness and safety of idarucizumab infusion for trial-eligible patients and all acute ischemic stroke patients. However, although it seems to be effective and safe, idarucizumab appears to be less effective in other trial-ineligible patients. Despite this result, our study provides further evidence for extending the applicability of idarucizumab in real-world scenarios. Our study suggests that idarucizumab can be a safe and effective option for reversing the anticoagulant effect of dabigatran, particularly for eligible patients.

Endoscopic cyanoacrylate injection therapy for refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy

Objective To evaluate the efficacy and safety of endoscopic cyanoacrylate injection therapy for refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy. Methods 154 patients with refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy at the Affiliated Hospital of Zunyi Medical Univesity and the People’s Hospital of Liupanshui City from January 2018 to December 2021were enrolled in this study. Endoscopic intracellular cyanoacrylate injection was first carried out. When failure, perintravascullar injection was carried out. The data were retrospectively collected. Results Among the 154 patients, 102 patients (66.23%) obtained successful intravascular injection and perivascular injection was performed in 52 patients (33.77%). Immediate hemostatic rate for active bleeding achieved 93.18%. Overall rebleeding rate within 30 days was 12.99% and successful hemostasis rate achieved 87.01%. Immediate hemostatic rate and successful hemostasis rate in intravascular injection patients were markedly superior over perivascular injection. Rebleeding rate in intravascular injection patients was markedly lower than that in perivascular injection patients. 14 patients complicated abdominal pain and no other complication occurred. Conclusion Endoscopic cyanoacrylate injection therapy, especial intravascular injection, was effective and safe, with high successful hemostasis rate for refractory high-risk peptic ulcer bleeding by conventional endoscopic therapy.

Endovascular therapy choices for different sites of delayed postoperative arterial hemorrhage after hepatobiliary pancreatic surgery: a retrospective study.

Angiography and subsequent endovascular therapy is an effective technique for delayed postoperative arterial hemorrhage (PAH) after hepatobiliary pancreatic surgery. In this research, we aimed to evaluate endovascular therapy choices for different sites of delayed PAH after hepatobiliary pancreatic surgery. A total of 85 patients with delayed PAH who underwent endovascular therapy at the Department of Radioactive Intervention of Eastern Hepatobiliary Surgery Hospital were retrospectively enrolled. According to the hemorrhage site, participants were divided into 3 groups, all of whom then received embolization, covered stent placement, or a combination of both. Ongoing or recurrent hemorrhages, intervention times, complications associated with intervention, and mortality rate were documented. The chi-squared (χ2) test was used for statistical analysis. A total of 22 participants with arterial branch hemorrhage underwent superselective embolization. Overall, 81.8% (18/22) of patients underwent embolization once. The successful hemostasis rate was 77.3% (17/22), and the mortality rate was 13.6% (3/22). A total of 53 participants with arterial trunk hemorrhage underwent embolization or covered stent placement. The rate of multi-time intervention, failure to achieve hemostasis, complications associated with intervention, and mortality was lower in the stent group than in the embolization group, and there was a significant difference in complications between the 2 groups (χ2=4.93, P=0.026). Among a total of 10 patients with multisite hemorrhage who underwent embolization, covered stent placement, or a combination, the successful hemostasis rate was 20%; and the mortality rate was 70%. Superselective embolization is a safe treatment method for arterial branch hemorrhage, and covered stent placement may be a better choice for arterial trunk hemorrhage. Verification of these findings is required via additional large population studies.

A125 SNARE TIP SPRAY COAGULATION FOR NON-CONTACT HEMOSTASIS: A SINGLE OPERATOR RETROSPECTIVE STUDY OF CLINICAL OUTCOMES.

Abstract Background An emerging non-contact endoscopic method for hemostasis is the use of spray coagulation (SC) using a polypectomy snare tip. Other non-contact options, such as argon plasma coagulation (APC), can be inconvenient and costly. Our current practice includes using SC where APC would be traditionally indicated. Aims The aim of this study was to characterize the clinical outcomes, including rates of successful hemostasis, rebleeding, and complications, for snare tip SC in hemostasis. Methods We conducted a retrospective chart review of all patients who underwent therapeutic endoscopy for hemostasis using snare tip SC by a single operator at a large Canadian tertiary care centre between January 2018 and September 2020. Results 14 patients, including 10 males and 4 females, were included. 5 (35%) patients received SC during an EGD, 5 (35%) patients during a colonoscopy, and 4 (29%) patients during a small bowel enteroscopy. Mean age was 74.4 (±11). All patients were referred for work-up of gastrointestinal bleeding or anemia. 5 (35%) patients were treated for vascular lesions including AVMs or angioectasias, 4 (29%) patients for GAVE, 3 (21%) patients for radiation proctitis, and 2 (14%) patients for bleeding ulcers. Adequate hemostasis, defined by cessation of bleeding symptoms, lack of a 10g/L or more decrease in hemoglobin post-procedure, and no further endoscopic therapies in the subsequent 28 days, was achieved in 11 patients (79%). 2 of the 3 patients in which adequate hemostasis was not achieved had additional investigations in which a second source of bleeding was found and treated. 1 patient with colonic AVMs and 1 patient with radiation proctitis required a repeat treatment in 2 weeks and 6 months, respectively. There were no incidence of prolonged abdominal pain, perforations or deaths. Conclusions Snare tip spray coagulation appears to be a safe and effective modality for non-contact hemostasis. Larger studies will help solidify its use in daily practice. Funding Agencies None

The Efficacy and Safety of Transcatheter Arterial Embolization to Treat Renal Hemorrhage after Percutaneous Nephrolithotomy.

Purpose The aim of this study was to evaluate the safety and efficacy of transcatheter arterial embolization (TAE) in patients with renal hemorrhage after percutaneous nephrolithotomy (PCNL) and evaluate the risk factors that may result in severe bleeding requiring TAE. Methods We retrospectively reviewed 121 patients with post-PCNL renal hemorrhage. Thirty-two patients receiving endovascular embolization were compared with 89 patients only receiving conservative treatment. The demographic and clinical data were recorded and compared between the two groups. The values of estimated glomerular filtration rate (eGFR) and serum creatinine (SCr) were recorded preoperatively, postoperatively, and at last follow-up and analyzed to evaluate the safety and efficiency of TAE. Results The successful hemostasis rate of conservative therapy was 73.6% (89/121) and that of TAE was 100% (32/32). SCr and eGFR were not significantly different before PCNL and after the last follow-up of TAE (SCr: 0.95 vs. 0.95 mg/dl, P=0.857; eGFR: 86.77 vs. 86.18 ml/min/1.73m2, P=0.715). The univariate analysis demonstrated that advanced age, urinary tract infection, and diabetes mellitus were significantly associated with severe bleeding during PCNL. Multivariate analysis further identified that diabetes mellitus was an independent risk factor for severe bleeding needing TAE [odds ratio (OR): 3.778, 95% confidence interval (CI):1.276-11.190, and P=0.016]. Conclusion TAE is a safe and effective procedure to treat renal hemorrhage that cannot be resisted by conservative treatment after PCNL. Diabetes mellitus was associated with high risks of severe bleeding needing TAE after PCNL.

Effectiveness of the polysaccharide hemostatic powder in non-variceal upper gastrointestinal bleeding: Using propensity score matching.

Recently, the application of hemostatic powder to the bleeding site has been used to treat active upper gastrointestinal bleeding (UGIB). We aimed to assess the effectiveness of the polysaccharide hemostatic powder (PHP) in patients with non-variceal UGIB. We reviewed prospectively collected 40 patients with UGIB treated with PHP therapy between April 2016 and January 2017 (PHP group) and 303 patients with UGIB treated with conventional therapy between April 2012 and October 2014 (conventional therapy group). We compared the rate of successful hemostasis and the rebleeding between the two groups after as well as before propensity score matching using the Glasgow-Blatchford score and Forrest classification. Thirty patients treated with the PHP and 60 patients treated with conventional therapy were included in the matched groups. Baseline patient characteristics including comorbidities, vital signs, and bleeding scores were similar in the matched groups. The rate of immediate hemostasis and 7-day and 30-day rebleeding were also similar in the two groups before and after matching. In the subgroup analysis, no significant differences in immediate hemostasis or rebleeding rate were noted between PHP in monotherapy and PHP combined with a conventional hemostatic method. At 30days after the therapy, there were no significant PHP-related complications or mortality. Given its safety, the PHP proved feasible for endoscopic treatment of UGIB, having similar effectiveness as that of conventional therapy. The PHP may become a promising hemostatic method for non-variceal UGIB.

Clinical endoscopic management and outcome of post-endoscopic sphincterotomy bleeding.

Post-endoscopic sphincterotomy bleeding is a common complication of biliary sphincterotomy, and the incidence varies from 1% to 48%. It can be challenging to localize the bleeder or to administer various interventions through a side-viewing endoscope. This study aimed to evaluate the risk factors of post-endoscopic sphincterotomy bleeding and the outcome of endoscopic intervention therapies. We retrospectively reviewed the records of 513 patients who underwent biliary sphincterotomy in Mackay Memorial Hospital between 2011 and 2016. The blood biochemistry, comorbidities, indication for sphincterotomy, severity of bleeding, endoscopic features of bleeder, and type of endoscopic therapy were analyzed. Post-endoscopic sphincterotomy bleeding occurred in 65 (12.6%) patients. Forty-five patients had immediate bleeding and 20 patients had delayed bleeding. The multivariate analysis of risk factors associated with post-endoscopic sphincterotomy bleeding were liver cirrhosis (P = 0.029), end-stage renal disease (P = 0.038), previous antiplatelet drug use (P<0.001), and duodenal ulcer (P = 0.023). The complications of pancreatitis and cholangitis were higher in the bleeding group, with statistical significance. Delayed bleeding occurred within 1 to 7 days (mean, 2.5 days), and 60% (12/20) of the patients received endoscopic evaluation. In the delayed bleeding group, the successful hemostasis rate was 71.4% (5/7), and 65% (13/20) of the patients had ceased bleeding without endoscopic hemostasis therapy. Comparison of different therapeutic modalities showed that cholangitis was higher in patients who received epinephrine spray (P = 0.042) and pancreatitis was higher in patients who received epinephrine injection and electrocoagulation (P = 0.041 and P = 0.039 respectively). Clinically, post-endoscopic sphincterotomy bleeding and further endoscopic hemostasis therapy increase the complication rate of pancreatitis and cholangitis. Realizing the effectiveness of each therapeutic modalities and appropriate management of different levels bleeding are important.

Starclose SE® hemostasis after 6F direct antegrade superficial femoral artery access distal to the femoral head for peripheral endovascular procedures in obese patients.

Direct superficial femoral artery (SFA) antegrade puncture is a valid alternative to common femoral artery (CFA) access for peripheral vascular interventions. Data investigating vascular closure device (VCD) hemostasis of distant SFA 6F access are limited. We aimed to investigate the safety and effectiveness of the Starclose SE® VCD for hemostasis, following direct 6F antegrade SFA access distal to the femoral head. This prospective, single-center study included patients who were not suitable for CFA puncture and were scheduled to undergo peripheral endovascular interventions using direct antegrade SFA 6F access, at least 2 cm below the inferior edge of femoral head. Hemostasis was obtained with the Starclose SE® VCD (Abbott Laboratories). Primary endpoints were successful hemostasis rate and periprocedural (30-day) major complication rate. Secondary endpoint was the rate of minor complications. Clinical and Doppler ultrasound follow-up was performed at discharge and at one month. Between September 2014 and August 2015, a total of 30 patients (21 male; 70.0%) with a mean body mass index of 41.2 kg/m2 were enrolled. Mean age was 72±9 years (range, 67-88 years). Most patients suffered from critical limb ischemia (87.1%) and diabetes (61.3%). Calcifications were present in eight cases (26.6%). Reason for direct SFA puncture was obesity (100%). Successful hemostasis was achieved in 100% of the cases. No major complications were noted after one-month follow-up. Minor complications included two <5 cm hematomas (6.6%) not necessitating treatment. In this prospective study, Starclose SE® VCD was safe and effective for hemostasis of antegrade direct SFA puncture. Uncomplicated hemostasis was achieved even in cases of puncturing 2 to 7 cm below the inferior edge of the femoral head.

Hemostatic effect of topical hemocoagulase spray in digestive endoscopy.

To evaluate the hemostatic effect of topical hemocoagulase spray in digestive endoscopy. Eighty-nine patients who developed oozing bleeding during endoscopic treatment from September 2014 to October 2014 at Center for Digestive Endoscopy, Tianjin Medical University General Hospital were randomly divided into either a study group (n = 39) or a control group (n = 50). The study group was given topical hemocoagulase spray intraoperatively, while the control group was given traditional 8% norepinephrine spray. Hemostatic efficacy was compared between the two groups. Bleeding site, wound cleanliness and perforation were recorded, and the rates of perforation and late bleeding were compared. Successful hemostasis was achieved in 39 (100%) patients of the study group and in 47 (94.0%) patients of the control group, and there was no significant difference in the rate of successful hemostasis between the two groups. Compared with the control group, after topical hemocoagulase spray in the study group, the surgical field was clearer, the bleeding site was more easily identified, and the wound was cleaner. There was no significant difference in the rate of perforation between the study and control groups (16.7% vs 35.0%, P = 0.477), but the rates of late bleeding (0% vs 15.8%, P = 0.048) and overall complications (P = 0.032) were significantly lower in the study group. Topical hemocoagulase spray has a definite hemostatic effect for oozing bleeding in digestive endoscopy, and this method is convenient, safe, and reliable. It is expected to become a new method for endoscopic hemostasis.

Long-term Results of Radiologically Guided Endoscopic Injection Sclerotherapy for Esophageal Variceal Bleeding: A Retrospective 30-year Survey

Background: Endoscopic injection sclerotherapy (EIS) is one of the most commonly applied techniques in the treatment of patients with bleeding esophageal varices (EV). However, the role of EIS in the long-term management of patients with EV bleeding remains controversial. We conducted a retrospective 30-year survey of EIS in patients with EV bleeding. Patients and Methods: Sclerosant with radiological contrast agent was endoscopically injected into the distal EV under fluoroscopic observation. The endpoint of injection was to fill the EV, including the supplying venous complex, which comprises the left and the short gastric veins. Results: Of the 367 patients reviewed, 350 had liver cirrhosis and 17 had idiopathic portal hypertension. The Child-Pugh classification was A in 92 patients, B in 121, and C in 154. Fifty-seven patients had hepatocellular carcinoma (HCC) at the initial EIS. The primary successful hemostasis rate was 95.5%. The numbers of re-bleeding EV episodes were 61 at 0 to 1 year, 34 at 1 to 3 years, 21 at 3 to 6 years, 2 at 6 to 9 years, and 0 over 10 years from the initial EIS intervention. EV was eradicated in 87% of patients and re-bleeding EV was markedly reduced after eradication of EV. Complications were generally mild, serious events were rare after 2000, included renal failure (3.3%), liver failure (3.3%), and esophageal stricture, and shock (1.6%), esophageal ulcer bleeding (1.6%). The causes of death were established in 278 patients, included liver failure (51.8%), HCC (20.9%), bleeding EV (7.9%), and procedure-related mortality (4.3%). The median survival time for all patients was 3.3 years, while 1-, 10-, 20-, and 30-year cumulative survival rates were 72.8%, 7.8%, 3.2%, and 3.2%, respectively. Conclusion: Our EIS treatment for bleeding EV was effective in reducing bleeding death over the long term. Improved survival requires amelioration of liver function and control of HCC.

A comparison study of local injection and radiofrequency ablation therapy for traumatic portal vein injure guided by contrast-enhanced ultrasonography

Background. To compare local injection of hemostatic agents and radiofrequency (RF)-assisted hemostasis in the management of bleeding from the portal vein with varying diameters and blood flow velocities.Material and methods. Sixteen Bama pigs were used. Laparotomy was performed to expose the liver and inner diameters and blood flow velocities of the pre-injured portal vein in the hepatic segments and subsegments were measured. Vascular injuries in the portal vein were produced (4 in each pig). The pigs were randomly divided into two groups and local injection of hemostatic agents was performed in one group and RF-assisted hemostasis in the other, both techniques monitored by contrast-enhanced ultrasonogra-phy (CEUS). Time to hemostasis was measured, and the extent of liver injury was determined 2 h after treatment.Results. In the local injection group, the rates of successful hemostasis were 100, 88.9, and 50% with portal veins with inner diameters of < 1 mm, 1-2 mm, and 2-3 mm, respectively, and the maximum time to achieve hemostasis was 24.0 ± 7.2 s. Hemostasis was not successful when the diameter was > 3 mm. In the RF-assisted group, hemostasis was successfully at all sites regardless of vessel diameter; however, the maximum time to achieve hemostasis was 156.8 ± 31.2 s. Injury to surrounding tissue was significantly greater in the RF-assisted group.Conclusion. Both methods can achieve hemostasis with small diameter portal vein injuries; however, RF-assisted hemostasis is necessary for larger vessels, though it is associated with greater damage to surrounding tissue.

Efficacy of endoscopic therapy for gastrointestinal bleeding from Dieulafoy’s lesion

To investigate the endoscopic hemostasis for gastrointestinal bleeding due to Dieulafoy's lesion. One hundred and seven patients with gastrointestinal bleeding due to Dieulafoy's lesion were treated with three endoscopic hemostasis methods: aethoxysklerol injection (46 cases), endoscopic hemoclip hemostasis (31 cases), and a combination of hemoclip hemostasis with aethoxysklerol injection (30 cases). The rates of successful hemostasis using the three methods were 71.7% (33/46), 77.4% (24/31) and 96.7% (29/30), respectively, with significant differences between the methods (P < 0.05). Among those who had unsuccessful treatment with aethoxysklerol injection, 13 were treated with hemoclip hemostasis and 4 underwent surgical operation; 9 cases were successful in the injection therapy. Among the cases with unsuccessful treatment with hemoclip hemostasis, 7 were treated with injection of aethoxysklerol and 3 cases underwent surgical operation; 4 cases were successful in the treatment with hemoclip hemostasis. Only 1 case had unsuccessful treatment with a combined therapy of hemoclip hemostasis and aethoxysklerol injection, and surgery was then performed. No serious complications of perforation occurred in the patients whose bleeding was treated with the endoscopic hemostasis, and no re-bleeding was found during a 1-year follow-up. The combined therapy of hemoclip hemostasis with aethoxysklerol injection is the most effective method for gastrointestinal bleeding due to Dieulafoy's lesion.

Prospective, Randomized Clinical Trial of the FloSeal Matrix Sealant in Cardiac Surgery

Topical hemostatic agents composed of a gelatin-based matrix and thrombin have been reported to be effective, in addition to traditional means, in terminating bleeding during cardiac operations. We compared a hemostatic matrix sealant agent (FloSeal; Baxter Inc, Deerfield, IL) with alternative topical hemostatic agents in a mixed cohort of elective cardiac and thoracic aortic operations. Following sample size calculation, in a prospective randomized study design, 209 patients were treated with FloSeal matrix sealant (FloSeal group) and 206 patients received alternative agents as topical hemostatic materials (comparison group). FloSeal is composed of a self-expandable gelatin matrix component and purified bovine thrombin. Comparisons included hemostatic patches or sponges composed of either oxidized regenerated cellulose or purified porcine skin gelatin. Study endpoints were the following: rate of successful intraoperative hemostasis (identified by cessation of bleeding) and time required for hemostasis; overall postoperative bleeding; rate of transfusion of blood products; rate of surgical revision for bleeding; postoperative morbidity; and intensive care unit stay. Statistically higher rates of successful hemostasis and shorter time-to-hemostasis were observed in the FloSeal group (p < 0.001 both). Time-to-event analysis confirmed this finding (p = 0.0025). Postoperative bleeding and rate of transfusion of blood products were statistically decreased in the FloSeal group (p < 0.001 both). Rates of revision for bleeding and of minor complications were not statistically different among groups in the overall cohort, but were significantly lesser in the FloSeal group if only patients with overt intraoperative bleeding are considered (p = 0.04 both). The advantages observed in the FloSeal group were not offset in patients undergoing systemic hypothermia. The topical hemostatic agent used in the FloSeal group is effective in terminating intraoperative bleeding as an adjunct to traditional surgical methods for stopping bleeding. Its judicious use is associated with lesser need for transfusion of blood products and rate of revision for bleeding. Its cost-utility profile should be addressed in dedicated trials.

Safe Injection Method for α- Cyanoacrylate Monomer (CA) in the Treatment of Gastric Fundal Variceal Rupture

Introduction: Management strategies for gastric fundal variceal rupture vary among institutions. We therefore studied whether our management method for this illness is effective. Subjects and Methods: Subjects were 18 cases of gastric variceal rupture that we encountered from 2000 to 2007. Their mean age was 59.9 ± 11.5 years and their Child-Pugh scores were: A for 10 cases; B for 7; and C for 1. Six cases were complicated by hepatocellular carcinoma . Our management procedures were as follows. The rupture point was punctured with a needle, which delivered 0.7 ml of the 100% CA inside the varicose vein. Additionally, the same amount of CA was injected so as to coat the puncture point while slowly drawing back the needle. While the needle was drawn out, the puncture site was lightly pressed with the endoscope tip to prevent the CA used for coating from shedding. The endoscope tip had a transparent hood to prevent backward flow of the CA, and the hood could be utilized for pressing on the variceal bleeding point. After stabilizing the patient's general condition by temporary control of hemorrhage, 3D-CT or angiography was carried out to determine the hemodynamic status of the varices. In cases with a gastro-renal shunt (G-R shunt), if the shunt diameter was 10 mm or greater, B-RTO was carried out, and if the diameter was less than 10 mm, EIS in combination with CA was conducted. In this study we assessed cases undergoing the latter management strategy for the rate of successful hemostasis, number of treatments, dose of CA, recurrence rate, and incidence of complications. Results: Hemorrhage was successfully arrested in all the subjects, the life-saving rate by means of hemostatis procedures being 100%. The mean number of treatments was 2.7 ± 1.2, and the amount of CA required to stop bleeding was 2.57 ± 1.39 ml. The cumulative recurrence rates at 1 and 3 years were 30 and 46.6%, respectively, while the cumulative rate of rebleeding was 0 and 28.6%, respectively. There were no severe complications. Conclusion: Our method to manage gastric variceal bleeding using CA injection was associated with no major complications and we were able to stop bleeding with a small amount of CA. Furthermore, CA never flowed to any other organ. Our method is so effective for the management of gastric fundal variceal rupture that it may become the standard therapeutic method.

Analysis of the treatment outcomes of esophageal variceal bleeding patients from multiple centers in China

This study aimed to investigate the treatment outcomes of esophageal variceal bleeding (EVB) in China. A total of 1087 cases were collected from 19 hospitals in 16 large and medium sized cities across China between January 1st, 2005 and January 1st, 2006. There were 313 cases (29.0%) of mild ( 1500 mL) bleeding. Successful hemostasis was achieved in 89.8% of cases. Seven hundred and eighty-five cases were treated by medication with a hemostasis rate of 91.8%. Seventy-one cases were treated using a Sengstaken-Blakemore tube with a hemostasis rate of 54.9%. Thirty-seven cases were treated with emergency endoscopic variceal ligation with a hemostasis rate of 83.8%. Seventy-seven cases were treated with endoscopic sclerotherapy with a hemostasis rate of 94.8%. Forty-three cases were treated with emergency surgical operation with a hemostasis rate of 95.3%. Sixty-six cases were treated with combined therapy with a hemostasis rate of 97.0%. There was a significant difference (P < 0.01) in the successful hemostasis rate between different treatments. The overall mortality was 10.1%, among which 6.6% was directly caused by bleeding. The multivariate logistic regression analysis shows that the severity of bleeding, treatment methods, liver dysfunction and activation of hepatitis were predictive factors for successful hemostasis. Most cases of EVB were mild and moderate in severity. The first-line treatment for EVB is medication. Emergency endoscopic intervention has not been widely available yet. The overall management outcome of EVB has been improved.

Endoscopic hemostasis by using the TriClip for peptic ulcer hemorrhage: a pilot study

The feasibility, efficacy, and safety of the TriClip in the management of peptic ulcer hemorrhage in human beings are scarcely reported in the literature. A pilot study was conducted to assess the feasibility, efficacy, and safety of the TriClip endoscopic clipping device in the control of peptic ulcer hemorrhage. Prospective evaluation. Regional government hospital. From July 2004 to January 2005, patients older than 16 years and with Forrest type I and IIa peptic ulcer hemorrhages were included in the study. TriClips were used for initial hemostasis. Salvage procedures, including adrenalin injection, heat probe application, argon plasma coagulation, or surgery will be carried out appropriately if TriClip failed to control bleeding alone. An endoscopy was repeated 24 hours later for the security of the TriClip and for any endoscopic evidence of recurrent bleeding. A follow-up endoscopy was performed 8 weeks later to assess ulcer healing. Procedure time, successful hemostatic rate, number of clips used, ulcer recurrent bleeding rate, complications, and ulcer healing rate were measured. No comparative arm; pilot study only. A total of 27 cases (11 women, 16 men) were included in the study, with a median age of 70 years (range 18-88 years). There were 19 cases of duodenal ulcer and 8 cases of gastric ulcer, with median size of 8 mm (range 2-20 mm). The rate of successful hemostasis in the first endoscopy by TriClips alone was 81.5% (22/27), with a median procedure time of 10 minutes (range 3-30 minutes). In the second endoscopy, the endoscopic recurrent bleeding rate was 14.8% (4/27) and the TriClips were found dislodged in 11 patients (40.7%). The permanent hemostasis rate was 67% (18/27). The overall failure rate was 33% (9/27). Three patients required blood transfusion before the first endoscopy. There was no morbidity or mortality observed in all cases. All ulcers healed after 8 weeks. The use of the TriClip is feasible in the initial control of peptic ulcer hemorrhage. However, we could not detect any obvious advantages in arresting bleeding vessels by using this new clipping device.