Systemic Anticoagulation Therapy Research Articles

Multifocal superficial thrombophlebitis of the extremities in HIV infection

Long-term observations indicate an increased risk of developing venous thromboembolic conditions in people with the human immunodeficiency virus, their tendency to relapse or a widespread nature. In addition, the incidence of thrombosis increases several times in HIV-infected people compared to the average rates characteristic of people of the same age. A clinical case of multiple bilateral lesions of the subcutaneous veins of the upper and lower extremities in a young patient with HIV infection is presented. Ineffective outpatient treatment and ascending superficial thrombophlebitis of the lower extremities required emergency hospitalization and surgical treatment of the patient to prevent thromboembolic complications. In the postoperative period, in order to prevent the progression of the thrombotic process, as well as to relieve the symptoms of an acute inflammatory reaction of the venous wall and paravasal tissues, a complex application of compression therapy, modern oral anticoagulant drugs, phlebotropic drugs with proven efficacy was carried out. The postoperative period proceeded without complications. In the next few days, the patient’s condition improved, there was a clear regression of thrombotic limb damage. Conclusion: In case of multiple thrombotic lesions of the subcutaneous veins of the upper and lower extremities on the background of HIV infection, the combination of timely surgical intervention with systemic anticoagulant therapy and phlebotropic agents of general and topical use has significant effectiveness in the medical rehabilitation of the patient.

PULMONARY EMBOLISM MANAGEMENT CHALLENGES IN DIAGNOSTIC AND TREATMENT OF 81 YEAR OLD MAN IN THE SETTING OF RURAL AREA WITH LIMITED RESOURCES : A CASE REPORT

Background: Pulmonary embolism is a cardiology emergency with a high mortality rate that is hard to diagnose for its symptoms. The adequate diagnosis of pulmonary embolism requires advanced laboratory and imaging facilities which are not widely available in Indonesia. The lack of facilities and pharmacological availability is an important problem for the delay of treatment and diagnosis of pulmonary embolism will increase the mortality number. This case reports on a patient with pulmonary embolism, managed in a limited healthcare facility. Case Illustration: A-81-year-old Man came with sudden dyspnea and hemoptoe. Physical examination showed mild tachycardia, a drop of blood saturation, and signs of right heart failure. His ECG showed deep S wave in lead I, Q wave in lead III (McGinn-white sign), P pulmonary in lead II, III, aVF, inverted T in inferior and anterior lead. Diagnosis were determined by the clinical score and the ECG pattern. The patient showed hemodynamic instability and was included as a high-risk pulmonary embolism, therefore systemic thrombolysis should be the goal therapy for this patient. Due to the unavailability of systemic thrombolysis, systemic anticoagulant therapy using fondaparinux sodium was initiated and hemodynamic support was given. The patient developed refractory shock despite the usage of the hemodynamic support and died after 5 days of hospitalization. Conclusion: The limitation of diagnostic tools and therapy is one of the biggest challenges in rural hospitals for it can increase the mortality rate of PE Patients. The procurement of diagnostic modalities and pharmacology therapies should be carried out in all hospitals in Indonesia to provide the best management for the patient.

Study to Evaluate the Role of Systemic Postoperative Anticoagulation Therapy in Patients Undergoing Medium-Sized Peripheral Artery Repair Following Trauma: a Randomized Controlled Trial

Study to Evaluate the Role of Systemic Postoperative Anticoagulation Therapy in Patients Undergoing Medium-Sized Peripheral Artery Repair Following Trauma: a Randomized Controlled Trial

A Phase II Study to Evaluate the Safety and Efficacy of Defibrotide in Children with High Risk Kawasaki Disease (IND 127812)

Background: Kawasaki disease (KD) is the leading cause of acquired heart disease in children in the developed world. It is an acute, generalized vasculitis, particularly in the coronary arteries, that occurs predominantly in infants and young children (Newburger et al, 2016). The acute phase of KD produces diffuse vascular inflammation that is thought to be associated with activation of the IL-1 pathway. Endothelium, located in the innermost layer of the coronary arteries, serves as an interface between the vascular media and circulating inflammatory cells and inflammatory cytokines. The coronary artery endothelium is the first target of the inflammatory attack in the early stages of KD (Qiu et al, Frontiers Cardiovascular Medicine, 2022) (Liu et al, Molecular Cell Biochem, 2021). There are pathologic changes during an acute arteritis with neutrophilic infiltration leading to necrosis in all the vessel walls, although the usual target is the medium sized extra-parenchymal muscular arteries. Current treatment is directed at reducing inflammation with IVIG and aspirin. Usually, this leads to rapid clinical improvement. However, 10-20% of patients are IVIG resistant and require further methods of reducing inflammation (Newburger et al, 2004). These patients that are IVIG resistant, have recrudescent fevers and evidence of ongoing inflammation, with subsequent increased risk for aneurysm formation (Tremoulet et al, 2008). Furthermore, other particular patient groups have been identified as having a higher risk (HR) of coronary artery aneurysms. Boys have a higher incidence of developing KD, but even accounting for that, are at a higher risk for developing coronary artery aneurysms (Belay et al, 2006). Defibrotide is a polydisperse mixture of predominantly single-stranded oligonucleotides (90% single-stranded and 10% double-stranded) derived from porcine intestinal mucosa. Several in vivo studies indicate that defibrotide primarily targets endothelium, particularly in small vessels, and appears to reduce endothelial cell injury and stabilize endothelial function (Falanga et al, Leukemia, 2003) (Cairo et al, BJH, 2020). Defibrotide is currently approved for SOS/VOD, with renal or pulmonary dysfunction post HSCT and has been well studied in infants with SOS post HSCT (Corbacioglu et al, Lancet, 2012). We hypothesized that Defibrotide will be safe and well tolerated in HR KD patients who fail IVIG and may be effective in difficult to treat KD patients, by mitigating ongoing endothelial dysfunction. Primary Aims: To determine the safety and efficacy of defibrotide in infants with HR KD. Design/Methods: Patients with KD as defined by the American Heart Association, have HR features (Table 1), age birth - 11 years of age, PT/PTT WNL, platelet count ≥100K/mm 3, and without active bleeding, hypersensitivity to defibrotide or receiving systemic anti-coagulant therapy, were eligible. Defibrotide, generously supplied by Jazz Pharmaceuticals, was administered within 96 hours of the conclusion of IVIG at 6.25 mg/kg IV Q6H (total daily dose 25 mg/kg/day) and continued for 7 days or until the patient was discharged from hospital, whichever occurred first (IND 127812) (NCT04777422). Stopping rules included: ≥ 15% grade III-IV allergic reaction or anaphylaxis or hemorrhage. All patients were treated with current standard of care, including: IVIG, aspirin (max 5mg/kg/dose), antibiotics, and intravenous fluids. Complete blood counts, coagulation studies and echocardiogram were performed at baseline, day 10, day 21, and 6 weeks after defibrotide was first given for disease assessment. Results: We have preliminary enrolled 2 patients (mean age of 31 months, range 15 months to 4 years) with a gender ratio of M/F 1/1 (Table 2). The median dose of defibrotide per patient was 5.5 (range 1-11) and the average hospital admission length was 5.5 days (range 5-6 days). No patients demonstrated heart abnormalities on baseline echocardiogram. There were no serious adverse events (SAE) probably or directly related to defibrotide, as evaluated by investigators. One patient had a grade II epistaxis, but no patients had any SAEs. Conclusion: This preliminary data suggests defibrotide is safe in children with HR KD failing IVIG. Further patients will be required to determine the safety and preliminary efficacy of defibrotide in children with HR KD. Supported in part by a research grant from Jazz Pharmaceuticals.

Abstract 130: Endovascular Therapy for Cerebral Venous Sinus Thrombosis: A Systematic Review of 267 patients

Introduction Cerebral venous sinus thrombosis (CVST) is a rare form of stroke that usually affects young females especially during pregnancy and the postpartum period. Several risk factors can contribute to the development of cerebral venous sinus thrombosis including hypercoagulable states, dehydration, infections, head or neck injuries, cancer, and some rheumatological diseases (1). The symptoms of cerebral venous sinus thrombosis can vary depending on the location and extent of the clot. Common signs and symptoms may include severe headaches, visual disturbances, seizures, focal neurological deficits, altered mental status, and in severe cases, coma. The initial treatment for CVST is systemic anticoagulation (2‐3). However, endovascular treatment (EVT) of CVST is typically reserved for cases associated with significant thrombus burden and lack of clinical improvement or worsening of symptoms despite systemic anticoagulation therapy without current conclusive evidence of its benefit. The aim of this study is to evaluate the evidence of EVT in patients with CVST. Methods A systemic literature search was conducted via PubMed to identify relevant studies. Only studies with sample sizes larger than 10 were included. We excluded small case series, meta‐analyses, systematic reviews, and studies that lack the main outcomes of interest. Our main outcomes included functional outcome defined as modified Rankin Scale score (mRS 0‐3), mortality, new or expanded ICH and recanalization rates. Results We finally included 10 studies (4‐13) in our qualitative synthesis. Only one study was a small, randomized clinical trial while the rest were observational studies. In our included studies, 267 patients underwent EVT for CVST. Among them, the median age was ranging from 12 to 75 and 162 (60 %) of patients were females. Patients were followed up for a mean ranging from 3 to 12 months. Recanalization was observed in 161 patients, out of which 111 were complete recanalization (68.9%) and 50 were partial recanalization (31.1%). Good functional outcome defined as mRS 0‐3 was achieved in a total of 181 patients. Additionally, 26 (9.7%) patients had a new onset or expanded ICH while 26 patients had died (9.7%). Conclusion EVT for CVST was associated with improved clinical outcomes with acceptable safety profile in severe cases. There is a lack of evidence from large randomized clinical trials so more prospective studies are needed to confirm these results.

Comparison of prevention and treatment of portal vein thrombosis between proximal splenic vein ligation followed by postoperative transcatheter anticoagulant therapy and systemic anticoagulant therapy in patients with cirrhotic portal hypertension

AbstractAimsSplenectomy combined with pericardial devascularization is one of the important methods to treat hypersplenism, gastrointestinal bleeding, and other complications caused by liver cirrhosis; however, it is accompanied by a high risk of portal vein thrombosis (PVT). This study aimed to explore the preventive and therapeutic effects of proximal splenic vein ligation (PSVL) with postoperative transcatheter anticoagulant therapy (TCAT) on PVT.MethodsThis study retrospectively selected 143 patients with liver cirrhosis and portal hypertension, who received splenectomy combined with pericardial devascularization from June 30, 2018 to June 30, 2021. According to computed tomography photography, within 1 week before the operation, the patients were divided into a prevention group (without preoperative PVT, n = 112) and a treatment group (preoperative PVT, n = 31). Then, each group was subdivided based on the treatment and prevention measures into PSVL + TCAT (n = 70) and systemic anticoagulant therapy (SAT) subgroups (n = 73). The preventive and therapeutic effects of PSVL followed by TCAT on PVT were analyzed.ResultsThe operation time in the PSVL + TCAT subgroups was longer than that in the SAT subgroups (185 ± 76 min vs. 161 ± 55 min; p < 0.01). There was no difference between the two subgroups in terms of operative bleeding (345 ± 82 mL vs. 336 ± 65 mL; p > 0.50). There was no operative death, and all patients recovered uneventfully. In the prevention group, procedure‐related complications occurred in two patients in the PSVL + TCAT subgroup (3.7% [2/54]), including one patient with slight pancreatitis and one patient with chylous leakage, owing to mobilization of the pancreas. The PVT incidence in the prevention group was significantly different between the two subgroups at postoperative 7th day, 3rd month, and 6th month (PSVL + TCAT: 0%, 11.1%, and 5.6% vs. SAT: 39.7%, 31.0%, and 20.7%, respectively; all p < 0.05). In the treatment group, the thrombus regression rate at postoperative 7th day and disappearance rates at the 3rd month and the 6th month of the PSVL + TCAT subgroup were significantly higher than those in the SAT subgroup after anticoagulant and thrombolysis therapy (PSVL + TCAT: 75.0%, 68.8%, and 87.5% vs. SAT: 20.0%, 26.7%, and 40.0%; all p < 0.05).ConclusionsPSVL + TCAT reduces the risk of PVT after splenectomy and is safe and effective in treating PVT during surgery for portal hypertension.

Feasibility of an implantable bioreactor for renal cell therapy using silicon nanopore membranes

The definitive treatment for end-stage renal disease is kidney transplantation, which remains limited by organ availability and post-transplant complications. Alternatively, an implantable bioartificial kidney could address both problems while enhancing the quality and length of patient life. An implantable bioartificial kidney requires a bioreactor containing renal cells to replicate key native cell functions, such as water and solute reabsorption, and metabolic and endocrinologic functions. Here, we report a proof-of-concept implantable bioreactor containing silicon nanopore membranes to offer a level of immunoprotection to human renal epithelial cells. After implantation into pigs without systemic anticoagulation or immunosuppression therapy for 7 days, we show that cells maintain >90% viability and functionality, with normal or elevated transporter gene expression and vitamin D activation. Despite implantation into a xenograft model, we find that cells exhibit minimal damage, and recipient cytokine levels are not suggestive of hyperacute rejection. These initial data confirm the potential feasibility of an implantable bioreactor for renal cell therapy utilizing silicon nanopore membranes.

A Case of Bilateral Sequential Sudden Sensorineural Hearing Loss in Protein S Deficiency and Successful Recovery of Hearing After Cochlear Implantation

Bilateral sequential sudden sensorineural hearing loss (SSHL) is a rare and challenging clinical condition, but its association with protein S deficiency has received limited attention. This paper reports a case of bilateral sequential SSHL in a patient with protein S deficiency who underwent cochlear implantation and achieved significant improvement in hearing. The patient received high-dose systemic corticosteroids and anticoagulation therapy before the implantation, which had no significant effect. Cochlear implantation was then performed in the left ear, and the patient showed significant improvement in speech understanding and overall hearing ability. A year later, the patient underwent surgery for the opposite ear with favorable outcome. This case highlights the potential benefits of cochlear implantation in patients with bilateral sequential SSHL and protein S deficiency and emphasizes the importance of considering cochlear implantation as a treatment option in such patients.

Contemporary Management of Acute Pulmonary Embolism: Evolution of Catheter-based Therapy.

Acute pulmonary embolism (PE) affects more than 100 000 people in the United States annually and is the third leading cardiovascular cause of death. The standard management for PE is systemic anticoagulation therapy. However, a subset of patients experience hemodynamic decompensation, despite conservative measures. Traditionally, these patients have been treated with systemic administration of thrombolytic agents or open cardiac surgery, although attempts at endovascular treatment have a long history that dates back to the 1960s. The technology for catheter-based therapy for acute PE is rapidly evolving, with multiple devices approved over the past decade. Currently available devices fall into two broad categories of treatment methods: catheter-directed thrombolysis and percutaneous suction thrombectomy. Catheter-directed thrombolysis is the infusion of thrombolytic agents directly into the occluded pulmonary arteries to increase local delivery and decrease the total dose. Suction thrombectomy involves the use of small- or large-bore catheters to mechanically aspirate a clot from the pulmonary arteries without the need for a thrombolytic agent. A thorough understanding of the various risk stratification schemes and the available evidence for each device is critical for optimal treatment of this complex entity. Multiple ongoing studies will improve our understanding of the role of catheter-based therapy for acute PE in the next 5-10 years. A multidisciplinary approach through PE response teams has become the management standard at most institutions. An invited commentary by Bulman and Weinstein is available online. Online supplemental material is available for this article. ©RSNA, 2022.

An Unusual Presentation of a Patient with Covid-19 Infection—Lemierre’s Syndrome

Lemierre’s syndrome refers to septic thrombophlebitis of the internal jugular vein that is rarely seen after an oropharyngeal infection. We present the case of a 64-year-old female patient with Covid-19 infection and Lemierre’s syndrome. Contrast-enhanced computed tomography of the neck revealed thrombosis in the left internal jugular vein and non-contrast-enhanced computed tomography of the thorax was consistent with Covid19 infection. The patient was immediately hospitalized. Systemic antibiotics, anticoagulation therapy, and favipiravir treatment for Covid-19 infection were started. Unfortunately, the patient died about two weeks after hospitalization. To the best of our knowledge, this is the first case of Lemierre’s syndrome and Covid-19 overlap. Clinical suspicion of Lemierre’s syndrome is important for rapid diagnosis. During this Covid-19 pandemic, we should keep in mind that any patient may have Covid-19 infection. In addition to the patient’s primary disease, with clinical or laboratory suspicion of Covid-19 infection, diagnostic tests for it should also be conducted.

Anesthetic Management in Parturients With Fontan Physiology

Anesthetic Management in Parturients With Fontan Physiology

Ultrasound-facilitated catheter-directed thrombolysis via dual right upper extremity venous access into the basilic vein in a case of submassive pulmonary embolism

Traditionally, massive, life-threatening pulmonary embolism (PE) has been treated with systemic thrombolytic therapy, whereas submassive and smaller acute PEs have been treated with systemic anticoagulation therapy. Given that thrombolytic therapy is associated with a risk of life-threatening complications, including intracranial hemorrhage, it has not been routinely used or recommended for submassive PEs. In 2017, the Food and Drug Administration (FDA) approved ultrasound-facilitated catheter- directed thrombolysis (USCDT) for acute massive and sub-massive pulmonary embolism. USCDT is primarily performed via jugular or femoral venous access. There have been isolated reports of USCDT performed via upper-extremity venous access. We present a case of ultrasound-facilitated catheter-directed thrombolysis (USCDT) in a submassive PE patient with dual right upper extremity venous access, where both sheaths were advanced into the basilic vein (due to anatomic variation). Based on recent clinical trial data suggesting that shorted duration USCDT is as effective as longer duration, tPA was infused in this case for 6 hours. This intervention strategy can enhance patient comfort with USCDT therapy and can be particularly helpful in patients at high risk of access site complications and those unable to lie supine for a long duration of infusion therapy.

LEMIERRE'S SYNDROME: THE FORGOTTEN DISEASE

TYPE: Case Report TOPIC: Chest Infections INTRODUCTION: Septic thrombophlebitis of the internal jugular vein (IJV) is a rare complication of anaerobic oropharyngeal infection. We present a case of Lemierre’s syndrome which was managed without systemic anticoagulation therapy. CASE PRESENTATION: A 63 year old female presented to the hospital with left jaw pain for one week. The admission labs were pertinent for leukocytosis, lactic acidosis, acute kidney injury and thrombocytopenia. Oral physical exam was significant for submandibular tenderness, ulcerative pharyngitis and tonsillitis. She was initiated on broad spectrum antibiotics. A venous ultrasound of the left upper extremity revealed an acute deep vein thrombosis in her left IJV and an acute superficial venous thrombosis in the right cephalic vein. The blood culture later grew an anaerobic gram negative bacteremia, identified to be part of the Fusobacterium species. The patient was managed on IV Unasyn for two weeks; she improved and her abnormal labs resolved. She was discharged with Amoxicillin for two weeks. DISCUSSION: The typical clinical picture of Lemierre’s syndrome is an acute oropharyngeal infection, anaerobic gram negative bacterial infection and an acute thrombosis of the internal jugular vein. Antibiotics are currently the primary treatment of this condition. Despite thrombosis of IJV, treatment with anticoagulation therapy remains unclear. CONCLUSIONS: We wish to highlight the importance of recognising Lemierre’s syndrome due to its increasing resurgence and high mortality rate (25%) if not treated adequately with antibiotics. This case also emphasises septic thrombophlebitis in the hospital setting and the need for further controlled studies to establish the role of anticoagulation therapy. DISCLOSURE: Nothing to declare. KEYWORD: lemierre's syndrome

Therapeutic anticoagulation using heparin in early phase severe coronavirus disease 2019: A retrospective study

BackgroundAlthough several reports recommend the use of systemic anticoagulation therapy in patients with severe coronavirus disease 2019 (COVID-19) pneumonia, appropriate target population and timing of administration are unknown. We assessed association between therapeutic anticoagulation administration with unfractionated heparin and outcomes in patients with severe COVID-19 pneumonia, assuming that anticoagulant administration effects are influenced by therapy timing. MethodsThis retrospective observational study included severe COVID-19 patients requiring mechanical ventilation in a tertiary emergency critical care hospital intensive care unit (ICU) in Japan from May 1, 2020 to September 30, 2021. All included patients were divided into early and late-phase administration groups based on therapeutic anticoagulant administration timing (≤5 and >5 days, respectively, after commencing oxygen therapy). Primary outcomes (in-hospital mortality and adverse events related to anticoagulation therapy) and secondary outcomes [veno-venous extracorporeal membrane oxygenation (ECMO), ventilator-free days (VFD), and ICU-free days] were compared between groups using univariate and multivariate models. ResultsOf 198 included patients 104 (52.5%) and 94 (47.5%) were in early-phase and late-phase administration groups, respectively. Although background characteristics were similar between the groups, the early-phase administration group had a significantly lower in-hospital mortality rate (3.8% vs. 27.7%; p < 0.001), lower adverse event rates (1.9% vs. 12.8%; p < 0.001), significantly longer VFD and ICU-free days, and lower ECMO rates, than the late-phase administration group, in the multivariate model. ConclusionsLate administration of therapeutic-dose anticoagulation in patients with severe COVID-19 pneumonia was significantly associated with worse outcomes than early administration.

A prospective ex vivo biomechanical analysis of retrievable inferior vena cava filters

ObjectiveIn the present study, we investigated the structural integrity of inferior vena cava (IVC) filters after their retrieval. MethodsA prospective ex vivo biomechanical analysis was performed of the structural integrity of 100 IVC filters used in a randomized controlled trial to evaluate the effectiveness of prophylactic IVC filters in preventing mortality or symptomatic pulmonary embolism in major trauma patients. ResultsOf the 100 included patients, 7 (7%) had required more than one attempt to remove the filter. The median duration of the filter left in situ was 54 days (interquartile range, 17-101 days). During the initial attempt to remove six filters (6%), thrombi were found entrapped and required 4 weeks of systemic anticoagulation therapy before the filters could be removed in a second attempt. A positive correlation was found between the duration of the filter left in situ and the loss in metallic elasticity of the nitinol alloy of the filter struts (Pearson correlation coefficient, 0.232; P = .008). One filter was adherent to the IVC wall and required open surgical removal 227 days after its initial placement. One of the six long struts of the filter had been fractured during the removal process, with evidence of hardening to bending stress in the remaining five struts of the fractured filter compared with the struts of the 25 intact filters. Fibrous endothelial tissue (73%) and thrombi (33%) adherent to the retrieved filters were frequently observed. The presence of adherent fibrous tissue was not significantly related statistically to the duration of the filter left in situ (P = .353) but was more common among the patients who had had a delay in receiving prophylactic anticoagulation therapy (mean difference, 2 days; 95% confidence interval, 0.6-3.3; P = .039). ConclusionsMetallic fatigue might account for IVC filter strut fractures. Fibrous endothelial tissue adherent to the filters was common, especially for those with a delay in receiving prophylactic anticoagulation therapy.

Recurrent acute portal vein thrombosis with severe abdominal infection after right hemihepatectomy in a patient with perihilar cholangiocarcinoma: A case report and literature review.

Introduction and importancePortal vein thrombosis (PVT) is a serious complication after hepatobiliary-pancreatic surgery. There have been few studies on recurrent PVT after hepatectomy for perihilar cholangiocarcinoma.Case presentationWe report the case of a 66-year-old woman who was diagnosed with perihilar cholangiocarcinoma and treated with right hemihepatectomy. On the sixth day, the patient developed acute portal vein thrombosis, and emergency portal vein incision and surgical thrombectomy were performed. On the seventh day after thrombectomy, the patient developed acute portal vein thrombosis again, and portal vein thrombectomy+portal vein bridging was performed again. There was still thrombosis after the operation. The patient was then treated with superior mesenteric arteriography + indirect portal vein catheterization thrombolysis and local thrombolysis + anticoagulation and systemic anticoagulation therapy. The patient had a complicated abdominal infection. The total hospital stay was 84 days. There was no thrombosis in the portal vein at discharge.Clinical discussionAlthough the procedure was carefully performed with a preoperative plan and fine intraoperative vascular anastomosis, postoperative PVT occurred. There are many factors of portal vein thrombosis, and there are many treatment methods.ConclusionPVT often develops in patients with liver cirrhosis postoperatively and after liver transplantation. Recurrent PVT after hepatectomy for perihilar cholangiocarcinoma is a rare complication.

Acute kidney infarction: Not so rare renal disease. A single-center experience with endovascular fibrinolytic therapy

Renal Infarction (RI), a rare cause of renal damage characterized by the abrupt interruption of flow in the renal artery, is often recognized late or may even remain undiagnosed since symptoms are non-specific and may be confused with other pathologies, such as pyelonephritis or nephrolithiasis. In situ thrombosis and thromboembolism are the main causes, but often the real cause is, gf unrecognized. The disease is often underdiagnosed and the diagnosis of certainty can be established with ultrasonography Doppler of renal arteries or with second-level diagnostic tools (contrast-enhanced computer tomography, magnetic resonance with gadolinium, and renal scintigraphy) or third level tests (renal arteriography). The therapeutic approach depends on the cause of RI, from the time from onset of ischemia, from the presence of kidney function impairment, and may include systemic anticoagulant therapy, renal angioplasty with or without stenting, loco-regional endovascular fibrinolytic therapy or surgery, as the last chance. In literature, there are neither guidelines nor evidence about any treatment superiority. Here we describe a paradigmatic case in a 51-years-old man hospitalized because of sudden flank pain: the clinical picture, the high serum level. Moreover, we report our 7-years’ experience with 24 cases of RI, mean age 70 /±15 years, 14/24 men, 16/24 presented with hematuria, frequently associated with the history of CKD (16/24). Fifteen of them (62%) were classified as idiopathic and 9 of them were successfully treated with endovascular fibrinolytic treatment. A review of the literature is also provided.

Efficacy of Stent Thrombectomy Alone or Combined With Intermediate Catheter Aspiration for Severe Cerebral Venous Sinus Thrombosis: A Case-Series.

ObjectiveTo assess the safety and efficacy of stent thrombectomy alone or combined with intermediate catheter aspiration for severe cerebral venous sinus thrombosis.MethodWe retrospectively collected the clinical data of 7 patients with severe CVST who received endovascular treatment at our hospital from January 2017 to June 2020. The patients had at least one adverse prognostic factor (mental status disorder, comatose state, intracerebral hemorrhage, or thrombosis of the deep venous system).ResultsThe median age was 51 years. Three patients were women. Two or more venous sinuses were in involved in 5 patients. All patients received systemic anticoagulant therapy before endovascular therapy. Neurological deterioration was the main reason for patients with cerebral venous sinus thrombosis undergoing intravascular therapy. The median time from admission to intravascular therapy was 3 days (1–9 days). Primary endpoints: 6 patients (85.7%) had a modified Rankin scale score of 0 at day 90, and 1 patient (14.3%) had a modified Rankin scale score of 2 at day 90. Secondary endpoints: complete recanalization was achieved in 4 cases (57.1%) and partial recanalization in 3 cases (42.9%).ConclusionStent thrombectomy, combined with intermediate catheter aspiration, balloon dilation, and regional thrombolysis/anticoagulation treatment, is an effective strategy to treat severe cerebral venous sinus thrombosis patients who had inadequate response to anticoagulant therapy. This strategy can quickly eliminate the occluded venous sinus and improve prognosis of severe cerebral venous sinus thrombosis.

Inhaled nebulised unfractionated heparin for the treatment of hospitalised patients with COVID-19: A multicentre case series of 98 patients.

To determine the safety and efficacy-potential of inhaled nebulised unfractionated heparin (UFH) in the treatment of hospitalised patients with COVID-19. Retrospective, uncontrolled multicentre single-arm case series of hospitalised patients with laboratory-confirmed COVID-19, treated with inhaled nebulised UFH (5000 IU q8h, 10 000 IU q4h, or 25 000 IU q6h) for 6 ± 3 (mean ± standard deviation) days. Outcomes were activated partial thromboplastin time (APTT) before treatment (baseline) and highest-level during treatment (peak), and adverse events including bleeding. Exploratory efficacy outcomes were oxygenation, assessed by ratio of oxygen saturation to fraction of inspired oxygen (FiO2 ) and FiO2 , and the World Health Organisation modified ordinal clinical scale. There were 98 patients included. In patients on stable prophylactic or therapeutic systemic anticoagulant therapy but not receiving therapeutic UFH infusion, APTT levels increased from baseline of 34 ± 10seconds to a peak of 38 ± 11 seconds (P < .0001). In 3 patients on therapeutic UFH infusion, APTT levels did not significantly increase from baseline of 72 ± 20 to a peak of 84 ± 28 seconds (P = .17). Two patients had serious adverse events: bleeding gastric ulcer requiring transfusion and thigh haematoma; both were on therapeutic anticoagulation. Minor bleeding occurred in 16 patients, 13 of whom were on therapeutic anticoagulation. The oxygen saturation/FiO2 ratio and the FiO2 worsened before and improved after commencement of inhaled UFH (change in slope, P< .001). Inhaled nebulised UFH in hospitalised patients with COVID-19 was safe. Although statistically significant, inhaled nebulised UFH did not produce a clinically relevant increase in APTT (peak values in the normal range). Urgent randomised evaluation of nebulised UFH in patients with COVID-19 is warranted and several studies are currently underway.

Response Team Management of Acute Serious Pulmonary Embolism.

Response Team Management of Acute Serious Pulmonary Embolism.