Therapeutic Doses Of Anticoagulants Research Articles

Причины геморрагических осложнений у пациентов стационара, получающих лечебные дозы антикоагулянтов

Причины геморрагических осложнений у пациентов стационара, получающих лечебные дозы антикоагулянтов

Postoperative Deep Vein Thrombosis, Pulmonary Embolism, and Myocardial Infarction: Complications After Therapeutic Anticoagulation in the Patient With Spine Trauma.

A retrospective review (2001-2014) was conducted using prospectively collected data at a level I trauma center. We sought to determine the incidence and characteristics of complications occurring secondary to therapeutic anticoagulation in adult spine trauma patients. Numerous studies have assessed prophylactic anticoagulation after spine surgery, but none has investigated the risks of therapeutic doses of anticoagulation for treatment of postoperative thromboembolic events. Patients were included if they sustained a postoperative thromboembolic event (deep venous thrombosis, pulmonary embolism, or myocardial infarction). Patients were excluded if anticoagulation was subtherapeutic. Of 1712 patients, 62 who received therapeutic anticoagulation and 174 propensity-matched control patients who did not receive therapeutic anticoagulation were included in the study. Initial anticoagulation was obtained by heparin infusion (51%), low-molecular-weight heparin (LMWH, 46%), and warfarin (3%). Complications requiring unplanned reoperation occurred in 18% of anticoagulated patients and 10% of nonanticoagulated patients (P = 0.17). The reoperation rate after heparin infusion was 31% and after LMWH was 6.5% (P = 0.02). Epidural hematoma occurred in 3% and 1% of anticoagulated and nonanticoagulated patients, respectively. Multivariate logistic regression analysis of the two groups showed a trend toward increased risk of reoperation in the anticoagulation group. Analysis of the heparin infusion subgroup separate from the LMWH subgroup compared with the control group showed an increased risk of reoperation for any complication (odds ratio, 3.57; P = 0.01) and for bleeding complications (odds ratio, 43.1; P = 0.01). This is the first study to quantify complications secondary to postoperative therapeutic anticoagulation in spine patients. Postoperative spine trauma patients who underwent therapeutic anticoagulation experienced an unplanned reoperation rate of 18%, including a 3% incidence of spinal epidural hematoma. Therapeutic anticoagulation using heparin infusion seems to drive the overall rate of reoperation (31%) compared with LMWH. 3.

BSH Guideline: management of thrombotic and haemostatic issues in paediatric malignancy.

BSH Guideline: management of thrombotic and haemostatic issues in paediatric malignancy.

Risk Factors and Management of Venous Thromboembolic Diseases in Donor of Living Donor Liver Transplant

Background: liver transplantation surgically replaces a failing or diseased liver with one that is normal and healthy. At this time, transplantation is the only cure for liver insufficiency or liver failure because no device or machine reliably performs all of the functions of the liver. Aim of the Work: this study aimed to highlight risk factors of the venous thromboembolism in donors of living donor liver transplant and its management. Patients and Methods: this study included 40 patients who underwent hepatectomy for living donor liver transplant. All patients were evaluated extensively, including history and physical examination and specialty consultations when indicated. All patients did haematological studies to detect the risk factors of thromboembolic disease. Results: in patients with manifestations of venous thromboembolism 2 donors have single risk factor for venous thromboembolism and 4 donors have double risk factors. Conclusion: presence of multiple risk factors for venous thromboembolism led to increase in its incidence, so during preoperative assessment of the donors, if they have multiple risk factors for thrombosis some precautions should be taken to avoid venous thrombosis. Recommendations: preoperative precautions include heamatological consultations for the donors and prophylaxis dose of anticoagulant. Intra operative precautions included pneumatic calf pressure, elastic stocking. Finally postoperative precautions should be continued , these donors should take therapeutic doses of anticoagulants and follow up by lower limb venous duplex.

Association between aspirin use and deep venous thrombosis in mechanically ventilated ICU patients.

Deep venous thrombosis (DVT) is common in intensive care unit (ICU) patients. It is often silent and may be complicated by pulmonary embolism and death. Thromboprophylaxis with heparin does not always prevent venous thromboembolism (VTE). Aspirin (ASA) reduces the risk of VTE in surgical and high-risk medical patients but it is unknown if ASA may prevent DVT in mechanically ventilated ICU patients. We performed a retrospective chart review of critically ill patients who received mechanical ventilation for >72h and underwent venous ultrasonography for suspected DVT between Jan 2012 and Dec 2013. We excluded patients who were on therapeutic doses of anticoagulation or had coagulopathy. We used multivariable logistic regression to evaluate association between aspirin use and DVT during hospitalization. There were 193 patients. The mean ± SD age was 58 ± 15.7 years. Half were male. DVT was found in 49 (25.4%). DVT was found in the first 15 days of hospitalization in 67.3% of the patients. The majority (82.8%) received thromboprophylaxis with unfractionated or low molecular weight heparin. Fifty-six (29%) were on ASA. On multivariable regression analysis, ASA use was associated with a significant reduction in the odds of finding DVT (OR 0.39, 95% CI 0.16-0.94; p = 0.036). DVT is common in mechanically ventilated ICU patients despite the use of thromboprophylaxis. Aspirin may prevent DVT in such patients.

Management of venous thromboembolism in patients with glioma

BackgroundVenous thromboembolism (VTE) is a common complication among patients with glioma. However, data on the safety of therapeutic doses of anticoagulation is scarce in this patient population. ObjectivesThe purpose of this study is to evaluate the risk of intracranial hemorrhage (ICH) in glioma patients receiving therapeutic anticoagulation for VTE treatment. Patients and methodsWe conducted a case-control study including glioma patients with and without acute VTE from Jan 2010 to March 2015. Controls were matched based on age, gender and tumor grade. Result569 patients with glioma were identified, 76 (13.3%) developed acute VTE. Of the 70 patients treated with full dose anticoagulant therapy, 14 (20%) patients had a major bleeding including 11 (15.7%) ICH. The odds ratio for ICH in patients with glioma and VTE who were treated with anticoagulation compared to the control group was 7.5 (95% CI, 1.6–34.9) p=0.01. Overall survival was similar for VTE and control group (36 vs. 42months, p=0.93). ConclusionTherapeutic anticoagulation is associated with a 7-fold increase risk of ICH in glioma patients. Data emerging from this study support the need for high quality studies to evaluate the risk of ICH in patients with glioma and VTE.

Treatment of Venous Thromboembolism in Patients with Hematological Malignancies and Severe Thrombocytopenia: A Retrospective Cohort Analysis

Background: Venous thromboembolism (VTE), bleeding, and thrombocytopenia are common occurrences during treatment of hematological malignancies. When VTE is complicated by severe thrombocytopenia, the safety and efficacy of anticoagulation is unclear.Methods:Single center retrospective chart review of subjects between 4/2004-12/2015 with active hematological malignancy and either 1) acute or chronic VTE on anticoagulation before platelet count dropped below 50k/µL or 2) acute VTE occurring while platelets were <50k/µL. Primary outcomes: time to recurrent VTE or clinically significant bleeding within 100 days from onset of severe thrombocytopenia. Exclusion criteria: age <18 years, hospice care, heparin-induced thrombocytopenia, thrombotic thrombocytopenic purpura, or contraindication to anticoagulation (excluding thrombocytopenia). Charts were reviewed to determine anticoagulation management strategy during episodes of severe thrombocytopenia and to confirm primary outcomes.Kaplan-Meier curves were created from time to event data for recurrent VTE and clinically significant bleeding by anticoagulation strategy and was censored for death, lost to follow up, and the opposite outcome. Incidence rates (IR) and incidence rate ratios (IRR) were calculated using person time with platelets<50k/µLfor recurrent VTE, clinically significant bleeding, and combined incidence of bleeding or recurrent VTE (composite outcome).Results: Over 11.5 years, 78 patients met inclusion criteria. Mean age was 53 years (range 19-81) and median duration of severe thrombocytopenia was 14 days (IQR 6-35). The initial treatment strategies when platelets dropped below 50k/µL were (i) therapeutic dose of anticoagulation with supportive platelet transfusions to maintain a count > 40-50,000/µL (n=43, 55%), (ii) no anticoagulation (n=33, 42%), and (iii) reduced or prophylactic dose anticoagulation (n=2, 3%). Clinically significant bleeding occurred in 13 patients with a median number of days to bleed of 8 (interquartile range 5-22) with the majority (n = 11, 85%) occurring on or before day 30 (Figure). Two patients experienced a life threatening bleed. Recurrent VTE occurred in 6 patients with a median number of days to recurrence of 62 (IQR 40-91) with the majority occurring after day 40 (n = 5, 83%: Figure). The median platelet count most proximate to event: bleeding, 38k/µL (range 5k-212k); recurrent VTE, 225k/µL (range 21k-407k). No recurrent VTE or bleeding resulted in death. Clinically significant bleeding within 100 days after the onset of severe thrombocytopenia occurred in 12/45 (27%) patients receiving anticoagulation vs. 1/33 (3%) patients when anticoagulation was held (IRR 17.7, 95% CI 2.62-756.98). Recurrent VTE occurred in 1/45 (2%) patients in the anticoagulation group versus 5/33 (15%) patients when anticoagulation was held (IRR 0.3, 95% CI 0.01-2.64). The composite outcome occurred in 13/45 (29%) patients in the anticoagulation group versus 6/33 (18%) patients when anticoagulation was held (IRR 3.2, 95% CI 1.13-10.26).Conclusions:The significantly higher rate of major bleeding and composite outcome in patients getting therapeutic dose anticoagulation with supportive platelet transfusions during episodes of severe thrombocytopenia raises concerns over this treatment as the primary management strategy for VTE in patients with hematological malignancies and severe thrombocytopenia. Initially, bleeding risk is high on anticoagulation yet the risk of recurrent VTE is low. However, with time and platelet recovery these risks reverse. The fluctuating risk of bleeding and recurrent VTE over time in patients with hematological malignancies and severe thrombocytopenia illustrates that anticoagulation strategies should vary in aggressiveness depending on degree and duration of thrombocytopenia.Safety and efficacy trials incorporating dynamic risk-adapted anticoagulation strategies are urgently needed to determine the best treatment strategy for VTE occurring in patients with hematologic malignancies and severe thrombocytopenia.Acknowledgments: Supported by NIH CTSA at the University of North Carolina (UL1TR001111) and UNC Hematology T32 (5T32HL007149-39). [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Efficacy of Therapeutic Dose Versus Prophylactic Dose of Anticoagulants in the Primary Prevention of Thrombotic Events in Ambulatory Patients with Solid Malignancies Receiving Chemotherapy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Vascular thromboembolism (VTE) is a recognized complication of cancer. Clinical trials have demonstrated varying degrees of efficacy of antithrombotic agents in preventing VTE in patients suffering from cancer. Benefit of anticoagulants was found to be more pronounced among patients who are at a higher risk for VTE such as patients with advanced cancer and patients undergoing chemotherapy and/or radiotherapy. However, the optimal dose of anticoagulants used in these settings remains unknown. Therefore, we have performed a systematic review and meta-analysis of randomized controlled trials (RCT) to evaluate the efficacy of different dosing of anticoagulants in the primary prevention of VTE among patients with advanced solid malignancies receiving chemotherapy.Methods: We undertook an extensive electronic database search using PUBMED and EMBASE databases for eligible studies. RCTs, involving patients with advanced solid malignancies receiving chemotherapy, which reported VTE rates as a primary or secondary outcome were included. RCTs that had a mixed population of patients such as all stages of cancer, solid and hematologic cancers, and chemotherapy and non-chemotherapy patients were excluded. The primary outcomes in this analysis were all reported VTE events and major bleeds. The secondary outcome was overall mortality rate. We used Comprehensive Meta-analysis Version 2 (Biostat, Englewood NJ) to estimate the pooled event-based risk ratio (RR) and risk difference (RD) with 95% confidence interval (CI) by using Mantel-Haenszel method. Random effects model was applied because of heterogeneity among the studies.Results: Eight RCTs comprising 6,492 patients (5 RCTs using prophylactic dose (n = 5,556), 1 RCT using semi-therapeutic dose (n = 312), 2 RCTs using therapeutic dose (n = 624)) are eligible for analysis. The duration of thromboprophylaxis ranged from 6 weeks to 6 months. The crude VTE rates were 2.65% and 5.66% in thromboprophylaxis and control groups, respectively, with an overall RR of 0.48 (CI = 0.36 – 0.64). RRs for VTE in patients receiving prophylactic, semi-therapeutic and therapeutic doses of anticoagulants were 0.48 (CI = 0.33 – 0.68), 0.35 (CI = 0.16 – 0.75) and 0.62 (CI = 0.33 – 1.16), respectively. The RRs of these subgroups were not significantly different from one another (p = 0.518). The overall RD was -0.024 (CI = -0.033 – -0.016), suggesting an estimated number needed to treat (NNT) of 42 (CI = 30 – 63) to prevent one VTE event. RRs for major bleeding across different antithrombotic doses were not statistically different (p = 0.44) with RRs of 1.1 (CI = 0.69 – 1.75), 0.63 (CI = 0.29 – 1.37) and 1.16 (CI = 0.52 – 2.58) for prophylactic, semi-therapeutic and therapeutic doses, respectively. The overall RR for major bleeding was 0.99 (CI = 0.69 – 1.41). There was no difference in mortality rate between thromboprophylaxis and control groups (RR = 0.98, CI = 0.92 – 1.04, p = 0.42). However, there was a nonsignificant trend towards improvement in mortality in the therapeutic dose subgroup (RR = 0.9, CI = 0.78 – 1.05, p = 0.17).Conclusions: Our meta-analysis demonstrated that, among patients with advanced solid malignancies receiving chemotherapy, primary thromboprophylaxis with anticoagulants significantly reduced VTE events without an increase in major bleeding events compared to control, even though an overall survival benefit was not observed. The benefit in VTE reduction, the risk of major bleeding events and the incidence of overall mortality were similar among the three dosing regimens. However, it was noted that there was a nonsignificant trend towards survival advantage in the therapeutic dose subgroup. [Display omitted] [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Paroxysmal Nocturnal Hemoglobinuria With Budd-Chiari Syndrome Treated With Complement Inhibitor Eculizumab; A Case Report

Introduction Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired haemolytic anaemia caused by somatic mutation in the phosphatidylinositol glycan-complementation class A gene, resulting in absence of a key complement regulatory protein, CD59. Thrombosis occurs in up to 40% of PNH patients; it usually involves abdominal and cerebral veins and it is the leading cause of death disease related. Methods We describe the response to Eculizumab (Soliris, Alexion) in 28 years old male with PNH diagnosed as a consequence of Budd Chiari Syndrome, acute liver dysfunction, mild haemolytic anaemia and thrombocytopenia. Results The patient was admitted to the gastroenterology department with acute abdominal pain, fatigue, hemolytic anaemia, thrombocytopenia and transaminitis. Abdominal doppler ultrasonography (US) was immediately performed with detection of Budd Chiari Syndrome, portal vein thrombosis, initial portal hypertension and ascites. He was started on low dose low molecular weight heparin (platelets &lt; 40x10^9/L), but despite anticoagulation progressive liver damage occurred, with poor pain control and worsening ascites. At the same time, we observed rapid exacerbation of thrombocytopenia and increasing in hemolysis tests with lactate dehydrogenase (LDH) reaching 1766 U/L, unresponsive to steroids administration. Bone marrow biopsy was negative but peripheral blood flow cytometry characterized a large PNH clone (85% total red blood cells). Furthermore, liver biopsy identified advanced stage of idiopathic cirrosis. Eculizumab therapy was then initiated at a dose of 600 mg weekly for 4 weeks and then 900 mg every 14 days. During the first month, transaminases progressively normalized and platelets settled permanently above 40x10^9/L, allowing therapeutic dose of anticoagulation. LDH dropped from basal value of &gt;1000U/L to 600U/L and progressive reduction in abdominal pain was observed. Recanalization of portal vein thrombosis was found out at the US doppler after 6 weeks of anticoagulation, but recanalization of sovraepatic veins was not yet detectable. Conclusions Currently, after 17 Eculizumab administrations, platelets are 44 x 10^9/L, Hb 11.9 g/dl, AST 26 mg/dl, ALT 55 mg/dl, GGT 123 mg/dl, LDH 518 U/L. No further thrombotic episodes occurred, no ascites was detected as well as portal hypertension signs, performing ultrasonography monitoring. This case shows that Eculizumab can block intravascular haemolysis and platelet consumption and can improve hepatic failure, allowing full dose of anticoagulant as therapy for current thrombosis or as prophylaxis for future events. Disclosures: No relevant conflicts of interest to declare.

Limited Benefit Gained From Inferior Vena Cava Filter Insertion In Patients With Advanced-Stage Cancer

▪ IntroductionCancer and its treatment are recognized risk factors for venous thromboembolism (VTE). Inferior Vena Cava (IVC) filters are utilized to provide mechanical thromboprophylaxis to prevent pulmonary embolism (PE) or to avoid bleeding from systemic anticoagulation in high risk patients. Patients and MethodsThis study was performed at a stand-alone, Joint Commission International (JCI)-accredited comprehensive cancer center. Hospital database was searched for all patients discharged with IVC filter insertion. Additionally, the radiology database was queried for cancer patients undergoing IVC filter placement. ResultsA total of 107 cancer patients; 59 (55.1%) males and 48 (44.9%) females who had their IVC filter inserted and followed up at our institution were included. The mean age (±SD) of the whole group was 50.8 (± 14.2) years. All patients had active cancer; the most common primary sites were gastrointestinal 32 (29.9%), brain 16 (15.0%) lung 13 (12.1%) and gynecological tumors 11 (10.3%). Majority of the patients had advanced-stage disease; out of 86 patients with identifiable TNM stage (Tumor, Node, Metastasis), 81 (94.2%) patients had locally-advanced stage III or metastatic stage IV disease, whereas only 5 (5.8%) had stages I or II disease.During the 6 weeks prior to IVC filter placement, 74 (69.2%) patients were on active anticancer therapy with 45 (42.1%) were on chemotherapy and 7 (6.5%) were on radiotherapy. Nineteen (17.8%) of the patients had surgical intervention for their cancer while only 3 (2.8%) were on hormonal therapy. The remaining 33 (30.8%) patients were on hospice and palliative care service with 18 (16.8%) were already placed “DNR” (Don't Resuscitate). Prior to IVC filter insertion, a diagnosis of DVT was made on 76 (71.0%) patients while 14 (13.1%) had PE; the other 17 (15.9%) had both DVT and PE.Contraindication to anticoagulation was the main indication for IVC filter placement reported in 85 (79.4%), while 18 (16.8%) had their filter inserted because of failure of anticoagulation (had DVT and/or PE while on therapeutic doses of anticoagulation). Other indications included large, free-floating iliocaval thrombus and poor compliance with anticoagulation.Filters were placed utilizing the jugular approach in 86 (80.3%) while 18 (16.8%) had their filter placed through a femoral approach. Complications following IVC filter placement occurred in 14 (13.1%); majority were recurrent DVT in 10 (9.3%), PE in 3 (2.8%) and filter thrombosis in one patient.Following IVC filter insertion, 42 (39.3%) were also anticoagulated; majority (86%) with LMWH (enoxaparin or tinzaparin). Twenty (47.6%) of these anticoagulated patients were considered, at the time of IVC filter insertion, as having a contraindication to anticoagulation.Survival data following IVC filter insertion was available for 100 patients. The median survival for the whole group was 2.39 months (range: 0.03-60.2). The median survival for patients with stage III and IV disease were 7.97 (1.90-17.08) and 1.31 months (0.92-2.20), respectively; p=0.0119; (Figure) Few patients had stage I and II disease (two had stage I while three others had stage II disease) and thus were excluded from survival analysis. [Display omitted] Among the 59 patients with stage IV disease for whom survival data was available, 23 (39.0%) survived less than a month, while 40 (67.8%) survived less than three months. Survivals of patients with stage III disease were better with only one out of 20 patients (5.0%) survived less than a month, while 14 (70.0%) survived more than three months. ConclusionsCancer patients with advanced-stage disease may gain little benefit from IVC filter insertion, so disease stage and life expectancy should be taken in consideration prior to filter placement. Disclosures:No relevant conflicts of interest to declare.

Massive Gastrointestinal Hemorrhage as a Complication of the Flexi-Seal Fecal Management System

Use of the Flexi-Seal fecal management system, a safe and effective means of fecal diversion in patients with fecal incontinence and diarrhea, can be associated with rare, life-threatening complications. For example, a critically ill patient had 2 episodes of massive rectal bleeding associated with use of the system that required transfusion of blood products. Hemorrhage was controlled during the first episode by angiography with selective coil embolization; the second required colonoscopy with suture ligation of the affected lesion. A literature review revealed 9 other cases that were managed endoscopically, surgically, or with angiography. Although none of the patients died, they experienced obvious complications that required transfusion of blood products, endoscopy, surgery, use of conscious sedation or general anesthesia, angiography, and exposure to intravenous contrast material. Patients receiving therapeutic doses of anticoagulation and antiplatelet drugs, which may precipitate or aggravate hemorrhaging, are particularly at risk for complications with the Flexi-Seal system.

Safety and Feasibility of a Diagnostic Algorithm Combining Clinical Probability, D-Dimer and Ultrasonography in Suspected Upper Extremity Deep Vein Thrombosis: A Prospective Management Study

AbstractAbstract 391 IntroductionTraditionally, the focus of VTE diagnostic is on deep vein thrombosis (DVT) of the leg and pulmonary embolism. Until recently, upper extremity DVT (UEDVT) was regarded as an uncommon and relatively benign presentation of venous thromboembolism; however, the more widespread use of central venous catheters has caused a significant increase in its incidence. Moreover, recent data indicate that 10–25% of these patients may have pulmonary embolism. Therefore, effective and safe diagnostic strategies are needed. The use of an algorithm combining a clinical decision score, D-dimer and ultrasonography is well-established for suspected lower limb DVT, but has not been evaluated in suspected UEDVT. This diagnostic management study assessed the safety and feasibility of a new diagnostic algorithm in patients with clinically suspected UEDVT. MethodsIn- and outpatients with suspected UEDVT were recruited from January 2010 until July 2012 in 17 hospitals in Europe and the United States. To confirm an acceptable failure rate of excluding UEDVT (upper 95% confidence interval below 3%), approximately 400 patients needed to be included. Main exclusion criteria were previous UEDVT and the use of therapeutic doses of anticoagulants. Informed consent was obtained from all participants. The algorithm consisted of the sequential application of the Constans' clinical decision score (Constans et al, Thromb Haemost 2008), D-dimer testing and compression ultrasonography. Patients were first categorized as UEDVT likely or unlikely by the Constans' score. In the patients with an unlikely score and a normal D-dimer, UEDVT was considered excluded and no further testing was done. All other patients underwent compression ultrasonography, which first assessed the deep veins for the presence of UEDVT and then the superficial veins for the presence of superficial vein thrombosis (SVT). Ultrasonography was repeated in case of an indeterminate ultrasonography result, or in patients with a high probability score, abnormal D-dimer and a normal ultrasonography. The primary outcome was the 3-month incidence of symptomatic UEDVT and pulmonary embolism in patients with a diagnostic work-up excluding both UEDVT and SVT. ResultsThe study population comprised of 356 consecutive patients with suspected UEDVT. The algorithm was feasible and completed in 96% (Figure). Of the 356 patients, 181 had a low probability score and D-dimer was measured. In 78 patients (22%) a normal D-dimer combined with a low probability score excluded UEDVT without any imaging, and these patients all had an uneventful 3 month follow up. An abnormal D-dimer test result was found in 100 patients, who underwent ultrasonography. In 3 patients, D-dimer measurement was not done, and these patients received ultrasonography right away. Of all patients with a low probability score, 15 patients had UEDVT, 24 patients had SVT, while thrombosis (both deep and superficial) was excluded in 141 patients. One remaining patient died of progressive cancer before ultrasonography could be done. All 175 patients with a high probability score underwent compression ultrasonography right away, which was repeated if indicated. Of these patients with a high probability score, 82 had UEDVT and 22 had SVT. In 71 patients, thrombosis was excluded, including 11 patients in whom the protocol was not followed completely. To summarize, of the 356 included patients, 97 patients had UEDVT (27%), 46 had SVT (13%) and in 212 patients the algorithm excluded UEDVT and SVT (60%). Of all patients in whom the algorithm excluded UEDVT and SVT, one patient developed UEDVT during follow-up for an overall failure rate of 0.47% (95%CI: 0.0–2.6%). Final results of the definitive study population of 407 patients will be presented. ConclusionsA new diagnostic algorithm which combines a clinical decision score, D-dimer and ultrasonography can safely and effectively exclude venous thrombosis of the upper extremity. This approach is attractive as it is simple, quick and non-invasive, and very similar to the well established algorithm for suspected DVT of the leg which could facilitate its implementation in clinical practice. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

The safety of anticoagulation in patients with intracranial aneurysms

Background and purposeLittle is known about the safety of long-term anticoagulation in patients with unruptured saccular intracranial aneurysms, although case reports of anticoagulation in patients with fusiform and saccular aneurysms...

Indications, Complications and Management of IVC Filters in 952 Patients At An Academic Hospital with a Level 1 Trauma Center

Abstract▪2285▪This icon denotes a clinically relevant abstract Introduction:Inferior vena cava (IVC) filters are frequently placed for the treatment and prevention of venous thromboembolism (VTE). Despite limited data to support their safety and efficacy, filter use has increased over the last three decades at our institution, as it has in hospitals throughout the United States. Boston Medical Center (BMC), a 500-bed academic institution with more than 30,000 admissions per year, is the largest and busiest Level 1 Trauma Center in New England. This study investigated the indications for IVC filter placement at BMC and examined outcomes including filter complications, management of anticoagulation, and follow up. Methods:A search was performed after obtaining IRB approval using Current Procedural Technology (CPT) codes to determine the number of patients at BMC that had IVC filters placed from August 2003 to February 2011. IVC filters were placed in 978 patients during the study period. Of these, 26 patients were excluded due to incomplete medical records. The remaining 952 charts were reviewed to determine patient demographics, indication for IVC filter placement, complications, post-discharge follow-up, filter retrieval, and use of anti-coagulation. Results:Of the 952 filters for which data were available, permanent filters were placed in 273 patients (29%), with the majority of these placed prior to 2006. Retrievable filters were placed in 679 patients (71%). Seven different types of IVC filters were placed by physicians from multiple departments, in decreasing order of frequency: interventional radiology, trauma surgery, vascular surgery, cardiology, and cardiothoracic surgery. Filters were successfully placed in the IVC in all patients except one, in whom a portion of the filter entered the renal vein and could not be extracted. The majority of filters were placed due to perceived immediate contraindication to anticoagulation (recent trauma, bleeding, or surgery). Five hundred and four patients (53%) had VTE at the time of filter placement with almost half of these, 237 patients (25% of all patients), received therapeutic anti-coagulation prior to discharge. A median of three days (range 0–32) elapsed between the date of trauma and filter insertion, with 174 (37%) being inserted five or more days after trauma. Only 31 patients (3%) sustained a VTE while on therapeutic anticoagulation. There was no protocol in place for routine imaging after filter placement or retrieval. Of the patients referred for subsequent imaging (approximately half) due to symptoms of VTE or other indications, 73 had VTE that developed after filter placement. Twenty-six of these events occurred during the index hospitalization. The majority of patients had follow-up at BMC within one month, although 207 patients had no documented follow-up at our institution. An attempt was made to remove 71 (10.5%) of the retrievable filters placed. Retrieval was successful in 58 of the 71 patients. Retrieval attempts failed in thirteen patients (18%) for the following reasons: filter embedded in the IVC, a clot in the filter, or a filter protruding through the blood vessel. The median retrieval time was 122 days (range 2 to 1931 days). The patient with retrieval at 1931 days had a fractured IVC filter removed with one prong extracted from a pulmonary artery. Conclusion:These data report on the largest single institution review of IVC filter placement and follow-up. Nine hundred and fifty-two filters were placed during the study period and 679 were filters designed for retrieval, yet only 58 retrievable filters (8.5%) were successfully removed. Unsuccessful retrieval occurred in 18% of attempts, making this a common and under-recognized problem. A significant proportion of filters placed for trauma were inserted after the period of highest bleeding risk had subsided, when anticoagulation may have been more appropriate. While many of these filters were placed under the generally accepted guideline of an existing contraindication to anticoagulation, 237 patients were discharged on therapeutic doses of anti-coagulation. Data are critically needed regarding indications for filter placement, risks and benefits of retrieving filters, and short and long-term complications of leaving filters in place. Disclosures:Sloan:Acetylon Pharmaceuticals: Consultancy; Millenium: Consultancy.

Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period

Venous thromboembolism (VTE) in pregnancy and the postpartum is an important cause of maternal morbidity and mortality; yet, there are few robust data from clinical trials to inform an approach to diagnosis and management. Failure to investigate symptoms suggestive of pulmonary embolism (PE) is a consistent finding in maternal death enquiries, and clinical symptoms should not be relied on to exclude or diagnose VTE. In this consensus statement, we present our recommendations for the diagnosis and management of acute deep venous thrombosis (DVT) and PE. All women with suspected DVT in pregnancy should be investigated with whole leg compression ultrasonography. If the scan is negative and significant clinical suspicion remains, then further imaging for iliofemoral DVT maybe required. Imaging should be undertaken in all women with suspected PE, as the fetal radiation exposure with both ventilation/perfusion scans and CT pulmonary angiography is within safe limits. Low-molecular-weight heparin (LMWH) is the preferred therapy for acute VTE that occur during pregnancy. In observational cohort studies, using once-daily regimens appears adequate, in particular with the LMWH tinzaparin; however, pharmacokinetic data support twice-daily therapy with other LMWH and is recommended, at least initially, for PE or iliofemoral DVT in pregnancy. Treatment should continue for a minimum duration of six months, and until at least six weeks postpartum. Induction of labour or planned caesarean section maybe required to allow an appropriate transition to unfractionated heparin to avoid delivery in women in therapeutic doses of anticoagulation.

Rates of venous thromboembolism in multiple myeloma patients undergoing immunomodulatory therapy with thalidomide or lenalidomide: a systematic review and meta‐analysis

The incidence of venous thromboembolism (VTE) in patients with multiple myeloma (MM) treated with thalidomide- and lenalidomide-based regimens is high. Recent observational studies have suggested that thromboprophylaxis might be efficacious in decreasing the risk of VTE in this population. To determine the absolute rates of VTE with and without different thromboprophylactic agents in patients with newly diagnosed or previously treated MM receiving thalidomide- or lenalidomide-based regimens. Patients with newly diagnosed MM treated with thalidomide in combination with dexamethasone have a VTE risk of 4.1 (95% CI, 2.8-5.9) per 100 patient-cycles. Therapeutic doses of anticoagulants seem to provide the largest absolute risk reduction of VTE. The rate of VTE in patients with previously treated MM receiving thalidomide in combination with dexamethasone is 0.8 (95% CI, 0.1-2.1) per 100 patient-months. A combination of lenalidomide and dexamethasone is associated with of risk of VTE of 0.8 (95% CI, 0.07-2.0) per 100 patient-cycles and 0.7 (95% CI, 0.4-0.9) per 100 patient-cycles in patients with newly diagnosed and previously treated MM, respectively. Similarly, the rates of VTE in patients also receiving thromboprophylaxis with aspirin were 0.9 (95% CI, 0.5-1.5) and 0.6 (95% CI, 0.01-2.1), respectively. Patients with newly diagnosed or previously treated MM receiving thalidomide- or lenalidomide-based regimens in combination with dexamethasone are at high risk of VTE. The benefit of various types of thromboprophylaxis is difficult to quantify in patients with MM receiving immunomodulatory therapy, especially in those receiving lenalidomide-based therapy or who have previously treated MM. Randomized controlled trials are needed to address this important clinical need.

Deep vein thrombosis and pulmonary embolism - Prevention, management, and anaesthetic considerations

There is high incidence of venous thromboembolism, comprising of deep vein thrombosis and pulmonary embolism, in hospitalized patients. The need for systemic thromboprophylaxis is essential, especially in patients with inherited or acquired patient-specific risk factors or in patients undergoing surgeries associated with high incidence of postoperative deep vein thrombosis and pulmonary embolism. These patients, on prophylactic or therapeutic doses of anticoagulants, may present for surgery. General or regional anaesthesia may be considered depending on the type and urgency of surgery and degree of anticoagulation as judged by investigations. The dilemma regarding the type of anaesthesia can be solved if the anaesthesiologist is aware of the pharmacokinetics of drugs affecting haemostasis. The anaesthesiologist must keep abreast with the latest developments of methods and drugs used in the prevention and management of venous thromboembolism and their implications in the conduct of anaesthesia.