CD248 enhances tissue factor procoagulant function, promoting arterial and venous thrombosis in mouse models

BACKGROUND

CD248 is a pro-inflammatory, transmembrane glycoprotein expressed by vascular smooth muscle cells (VSMC), monocytes/macrophages, and other cells of mesenchymal origin. Its distribution and properties are reminiscent of those of the initiator of coagulation, tissue factor (TF).

OBJECTIVE

We examined whether CD248 also participates in thrombosis.

METHODS

We evaluated the role of CD248 in coagulation using mouse models of vascular injury, and by assessing its functional interaction with the TF-factor VIIa (FVIIa)-factor X (FX) complex.

RESULTS

The time to ferric chloride-induced occlusion of the carotid artery in CD248 knockout (KO) mice was significantly longer than in wild-type (WT) mice. In an inferior vena cava (IVC) stenosis model of thrombosis, lack of CD248 conferred relative resistance to thrombus formation compared to WT mice. Levels of circulating cells and coagulation factors, prothrombin time, activated partial thromboplastin time, and tail bleeding times were similar in both groups. Proximity ligation assays revealed that TF and CD248 are <40 nm apart, suggesting a potential functional relationship. Expression of CD248 by murine and human VSMCs, and by a monocytic cell line, significantly augmented TF-FVIIa-mediated activation of FX, which was not due to differential expression or encryption of TF, altered exposure of phosphatidylserine or differences in tissue factor pathway inhibitor expression. Rather, conformation-specific antibodies showed that CD248 induces allosteric changes in the TF-FVIIa-FX complex that facilitates FX activation by TF-FVIIa.

CONCLUSION

CD248 is a newly uncovered protein partner and potential therapeutic target in the TF-FVIIa-FX macromolecular complex that modulates coagulation.

Case Report: Cerebral venous thrombosis revealing celiac disease

Celiac disease (CD) is an autoimmune enteropathy resulting from intolerance of an individual genetically predisposed to gluten. It has a large clinical polymorphism ranging from a classic digestive clinical presentation due to the malabsorption syndrome to extra-intestinal symptoms. Among the hematologic abnormalities, venous thromboembolic disease (VTE) has been reported, and they are most often located in the abdomen or lower limbs, but the cerebral localization was exceptionally described. We report a case of CD revealed by cerebral thrombophlebitis. A 44-year-old patient with no medical history and no drug intake, presented with hemiplegia followed by a status epilepticus in a context of apyrexia, initially hospitalized in intensive care. Magnetic imaging resonance displayed a cerebral venous thrombosis of the sigmoid sinus requiring anticoagulant treatment, then transferred to our department for the etiological investigation. On questioning, the patient reported chronic diarrhea and weight loss with no other associated symptoms. The examination revealed an underweight patient with pale conjunctiva, improvement of her deficit symptoms, and no other abnormalities. Laboratory tests noted biological signs of malabsorption. The thrombophilia assessment revealed a protein C deficiency with a slight increase in anticardiolipin antibodies and anti-Beta 2 glycoprotein 1 antibodies. Immunological tests noted positives anti-transglutaminase and IgA anti-endomysium antibodies. Duodenal biopsy demonstrated villous atrophy. After ruling out the other causes of VTE, the diagnosis of cerebral venous thrombosis secondary to CD was retained. Early diagnosis and treatment of CD improves the quality-of-life for patients and may spare them various long-term or even fatal complications.

Case Report: Cerebral venous thrombosis revealing celiac disease

Celiac disease (CD) is an autoimmune enteropathy resulting from intolerance of an individual genetically predisposed to gluten. It has a large clinical polymorphism ranging from a classic digestive clinical presentation due to the malabsorption syndrome to extra-intestinal symptoms. Among the hematologic abnormalities, venous thromboembolic disease (VTE) has been reported, and they are most often located in the abdomen or lower limbs, but the cerebral localization was exceptionally described. We report a case of CD revealed by cerebral thrombophlebitis. A 44-year-old patient with no medical history and no drug intake, presented with hemiplegia followed by a status epilepticus in a context of apyrexia, initially hospitalized in intensive care. Magnetic imaging resonance displayed a cerebral venous thrombosis of the sigmoid sinus requiring anticoagulant treatment, then transferred to our department for the etiological investigation. On questioning, the patient reported chronic diarrhea and weight loss with no other associated symptoms. The examination revealed an underweight patient with pale conjunctiva, improvement of her deficit symptoms, and no other abnormalities. Laboratory tests noted biological signs of malabsorption. The thrombophilia assessment revealed a protein C deficiency with a slight increase in anticardiolipin antibodies and anti-Beta 2 glycoprotein 1 antibodies. Immunological tests noted positives anti-transglutaminase and IgA anti-endomysium antibodies. Duodenal biopsy demonstrated villous atrophy. After ruling out the other causes of VTE, the diagnosis of cerebral venous thrombosis secondary to CD was retained. Early diagnosis and treatment of CD improves the quality-of-life for patients and may spare them various long-term or even fatal complications.

Portal vein thrombosis associated with high 14-day and 6-week rebleeding in patients after oesophageal variceal band ligation: a retrospective, multicentre, nested case-control study

BACKGROUND AND AIMS

The association between prognosis of variceal bleeding and portal vein thrombosis (PVT) is unclear. In this multicentre study, we determined the effect of PVT on rebleeding and mortality in patients with acute variceal bleeding (AVB) after oesophageal variceal band ligation (EVL).

METHODS

Cirrhotic patients with AVB who had undergone EVL were included. The patients were allocated to either the PVT group or the control cirrhotic group (CCG) based on the presence or absence of PVT. One-year rebleeding episodes and mortality after EVL were recorded.

RESULTS

A total of 218 cirrhotic patients with AVB from 3 centres were included. Patients with PVT had a higher rate of 14-day and 6-week rebleeding than those without PVT (14-day: 8.26% vs. 1.83%, p = 0.03; 6-week: 11.92% vs. 1.83%, p = 0.003). The rates of 5-day failure (3.67% vs. 0.92%, p = 0.175), 1-year rebleeding (21.10% vs. 20.18%, p = 0.867), and 14-day, 6-week, and 1-year mortality were similar between the groups (14-day: 3.67% vs. 0.92%, p = 0.175; 6-week: 3.67% vs. 0.92%, p = 0.175; 1-year: 3.67% vs. 1.83%, p = 0.408). The Child-Pugh class [p = 0.022, hazard ratio (HR): 1.453; 95% confidence interval (CI) 1.056-1.998], PVT (p = 0.050, HR: 4.622, 95% CI 0.999-21.395), albumin < 30 g/L (p = 0.023, HR: 5.886, 95% CI 1.272-27.245), and number of bands (p = 0.010, HR: 1.207, 95% CI 1.046-1.393) were identified as the predictors for 14-day rebleeding; the multivariate analysis revealed only the number of bands (p = 0.009, HR: 1.247, 95% CI 1.056-1.473) as the independent factor. PVT (p = 0.012, HR: 6.732, 95% CI 1.519-29.835) and albumin < 30 g/L (p = 0.027, HR: 3.643, 95% CI 1.160-11.441) were identified as predictors for 6-week rebleeding; however, only PVT (p = 0.015, HR: 6.380, 95% CI 1.427-28.515) was found to be the independent factor in the multivariate analysis. Further analysis showed that superior mesenteric vein (SMV) thrombosis is the only risk factor predicting 6-week rebleeding in patients with PVT (p = 0.032, HR: 3.405, 95% CI 1.112-10.429).

CONCLUSIONS

PVT was associated with high 14-day and 6-week rebleeding in patients after EVL. SMV thrombosis was the only risk factor for 6-week rebleeding in patients with PVT. High albumin levels may serve as a protective factor for the 14-day and 6-week rebleeding risk. PVT was not responsible for mortality after EVL during 1-year follow-up.

SARS-CoV-2 vaccine-induced cerebral venous thrombosis

The nosological entity of the cerebral venous thrombosis caused by the SARS-CoV-2 vaccination differs from the common cerebral venous thrombosis in that it is due to immune thrombocytopenia triggered by vaccination. Cerebral venous thrombosis is one of several manifestations of this type of immune thrombocytopenia. Albeit many general aspects of management of cerebral venous thrombosis are similar, immune thrombocytopenia requires a specific therapeutic approach, which is not normally adopted for cerebral venous thrombosis due to other causes, therefore its early recognition is essential.

Characterising the background incidence rates of adverse events of special interest for covid-19 vaccines in eight countries: multinational network cohort study

OBJECTIVE

To quantify the background incidence rates of 15 prespecified adverse events of special interest (AESIs) associated with covid-19 vaccines.

DESIGN

Multinational network cohort study.

SETTING

Electronic health records and health claims data from eight countries: Australia, France, Germany, Japan, the Netherlands, Spain, the United Kingdom, and the United States, mapped to a common data model.

PARTICIPANTS

126 661 070 people observed for at least 365 days before 1 January 2017, 2018, or 2019 from 13 databases.

MAIN OUTCOME MEASURES

Events of interests were 15 prespecified AESIs (non-haemorrhagic and haemorrhagic stroke, acute myocardial infarction, deep vein thrombosis, pulmonary embolism, anaphylaxis, Bell's palsy, myocarditis or pericarditis, narcolepsy, appendicitis, immune thrombocytopenia, disseminated intravascular coagulation, encephalomyelitis (including acute disseminated encephalomyelitis), Guillain-Barré syndrome, and transverse myelitis). Incidence rates of AESIs were stratified by age, sex, and database. Rates were pooled across databases using random effects meta-analyses and classified according to the frequency categories of the Council for International Organizations of Medical Sciences.

RESULTS

Background rates varied greatly between databases. Deep vein thrombosis ranged from 387 (95% confidence interval 370 to 404) per 100 000 person years in UK CPRD GOLD data to 1443 (1416 to 1470) per 100 000 person years in US IBM MarketScan Multi-State Medicaid data among women aged 65 to 74 years. Some AESIs increased with age. For example, myocardial infarction rates in men increased from 28 (27 to 29) per 100 000 person years among those aged 18-34 years to 1400 (1374 to 1427) per 100 000 person years in those older than 85 years in US Optum electronic health record data. Other AESIs were more common in young people. For example, rates of anaphylaxis among boys and men were 78 (75 to 80) per 100 000 person years in those aged 6-17 years and 8 (6 to 10) per 100 000 person years in those older than 85 years in Optum electronic health record data. Meta-analytic estimates of AESI rates were classified according to age and sex.

CONCLUSION

This study found large variations in the observed rates of AESIs by age group and sex, showing the need for stratification or standardisation before using background rates for safety surveillance. Considerable population level heterogeneity in AESI rates was found between databases.

[May-Thurner syndrome as a cause of abdominal pain: Case report]

BACKGROUND

The May-Thurner syndrome consists of an anatomical anomaly of the iliac veins that predisposes the person presenting it to the appearance of venous insufficiency and recurrent thrombotic episodes of the lower limbs. The aim of this article was to present a case of this pathology, highlighting a rare symptom that led to its diagnosis.

CASE REPORT

46-year-old woman with severe abdominal pain in the right iliac fossa not associated with other gastrointestinal symptoms or fever. Contrast tomography of the abdomen and pelvis reported bilateral common iliac vein thrombosis. After ruling out acute surgical abdomen or immunological pathologies, an abdominal-pelvic angiography was performed, which led to the diagnosis of May-Thurner syndrome. It was performed endovascularly, pharmaco-mechanical thrombolysis, balloon plasty, and stent installation.

CONCLUSIONS

This type of abdominal vascular compression syndromes are rare and require a high index of suspicion to be diagnosed, which is why publications of this type of pathology take on relevance since they teach readers about the pathology.

Venous thromboembolism in hospital emergency room. A retrospective study on climatic effect

Several cardiovascular conditions exhibit seasonality in frequency and mortality, but little is known about the seasonality of Venous ThromboEmbolism (VTE), a very relevant medical condition, and seasonal influences are still conflicting. Patients having co-morbidities, individual suffered from dyspnea, swelling, edema of lower limb, pain (chest, lower limbs) are admitted frequently to the hospital emergency room (HER), particularly. Both mark a potential risk for VTE, that can be increased also by seasonality. A four years retrospective analysis (2016-2019) was carried out in individuals and patients admitted to the HER of the Hospital of Catania (a Mediterranean city of Sicily, Italy) to evaluate the VTE frequency and its seasonal differences, common symptoms, potential usage of some common laboratory tests. Dyspnea, swelling, edema of lower limb and pain (chest, lower limbs) were considered to suspect pulmonary embolism (PE) or for deep vein thrombosis of lower limb (DVT). Platelet count, platelet volume, fibrinogen, C-reactive protein, and D-dimer were considered. VTE frequency per year was 2.9/10,000 (2016), 4.9/10,000 (2017) 3.6/10,000 (2018), and 5.1/10,000 (2019) respectively. Dyspnea was highly frequent for PE, edema and lower limb pain were frequent in DVT patients. Fibrinogen, C reactive protein, and D-dimer values were found raised in all the VTE patients. Platelet volume was found higher in DVT than PE VTE events that occurred in warm periods were modestly greater (57 VTE: 38 DVT, 19 PE) compared to cold months (52 VTE: 34 DVT, 18 PE). Our results could be explained by the increased sweating due to the high temperatures, which in turn, can affect both on plasma concentration and on hematocrit value coupled to the reduction in atmospheric pressure determining both a hyper-coagulative condition. Climate seasonal characteristics, and environmental conditions in Catania city (Sicily) may be as reasonable items in expecting on different VTE rates in warm period compared to cold. This study highlights no specific symptoms, and confirms the common lab tests for individuals and patients admitted to HER as simple and helpful tools in initiating none or mini-invasive diagnostic strategy for the VTE. Finally, the climate/seasonality coupled with latitude can have a direct influence on the incidence of DVT.

Hormonal contraceptive use in Denmark 2010-2019

INTRODUCTION

Hormonal contraception (HC) celebrates its 60th anniversary this year. Thanks to thousands of scientific studies on these products, we now have solid knowledge about the short- and long-term effects and also the adverse effects of different contraceptive types. The aim of this study was to analyse trends in the use of different types of HC through the latest decade in different age groups of Danish women and to study reasons for any changes.

METHODS

Individual-level HC sale statistics were provided from the National Registry of Medicinal Products. All statistics were stated as defined daily doses per 1,000 women per day. Absolute numbers and distributions among users were calculated.

RESULTS

The overall use of HC was stable in women from 15 to 25 years, decreased among women aged 25-34 years and increased among women aged 35 years or more. On average, an increase from 35% to 39% was recorded. Across all age groups, the use of second-generation combined oral contraceptives (COC) has almost completely replaced the use of third- and fourth-generation pills, and from the age of 20 years of age, the use of COC has decreased contrasting a steep increase in use of the hormone-intrauterine device (IUD). The magnitude of this shift increased with increasing age.

CONCLUSIONS

Whereas the overall use of hormonal contraception has increased over the latest decade from 35% to 39% among all women aged 15-49 years, hormone-IUDs have increasingly replaced COCs so that they are now dominating among women aged 30 years or more. These changes are expected to have decreased venous thrombosis and menorrhagic complaints in young women substantially.

FUNDING

Expenses were covered by Department of Gynaecology, Rigshospitalet.

TRIAL REGISTRATION

The Danish Data Protection Agency (R. no. 2015-41-4481).

Which Hormones and Contraception for Women with APS? Exogenous Hormone Use in Women with APS

PURPOSE OF REVIEW

Use of exogenous estrogen carries significant risk for patients with prothrombotic disorders including those with antiphospholipid antibody (aPL) and antiphospholipid syndrome (APS). This review summarizes current knowledge of contraceptive and other hormone therapies for aPL-positive and APS women and highlights knowledge gaps to guide future research.

RECENT FINDINGS

Studies support very low risk for most progestin-only contraceptives in patients with increased thrombotic risk, but suggest increased VTE risk with depot-medroxyprogesterone acetate. Highest efficacy contraceptives are intrauterine devices and subdermal implants, and these are recommended for women with aPL/APS. Progestin-only pills are effective and low risk. Perimenopausal symptoms may be treated with nonhormone therapies in aPL/APS patients: vasomotor symptoms can improve with nonhormonal medications and cognitive behavioral therapy, and genitourinary symptoms often improve with intravaginal estrogen that has limited systemic absorption.

Non-retrieved inferior vena cava filters: causes and long-term follow-up

BACKGROUND

Temporary inferior vena cava (IVC) filters are not always retrieved. Information about long-term outcomes of patients with indwelling filters is scarce. Aims of our study were to assess reasons that preclude retrieval of temporary IVC filters and long-term outcomes and causes of death in patients with indwelling filters.

MATERIALS AND METHODS

Retrospective observational study including all consecutive patients undergoing IVC filter insertion from January 2009 through December 2018. Patients with permanent filters and those with temporary filters not retrieved were followed from insertion until June 2020.

RESULTS

We included 271 patients with a mean age of 63.8 years. The main indication for filter insertion was acute venous thromboembolism and contraindication for anticoagulation (83%). The filter was deemed as permanent in 24.4% of patients and temporary in 75.6%. Sixty six percent of temporary filters were retrieved; the main cause of non-retrieval was lack of planning / follow-up (57.9%). One hundred twelve patients (41.3%) remained with indwelling filters. After follow-up, 54.5% were alive and 45.5% had died, with a median survival time of 6.19 (95% CI, 2.63-9.75) years. The most frequent cause of death during follow-up was cancer (49%). The frequency of anticoagulant therapy was similar in both groups (57.4%% versus 54.9%).

CONCLUSIONS

The main preventable cause of non-retrieval of temporary IVC filters was lack of planning / follow-up. Structured follow-up programs should be implemented to increase retrieval rates. In patients with indwelling filters, the main cause of death was cancer and extended anticoagulation was not associated with survival.

Clinical outcomes of radical surgery in patients with renal carcinoma and associated venous thrombosis: Single-centre experience in a tertiary care institution

BACKGROUND

Renal carcinoma and associated venous thrombosis cause specific perioperative and postoperative challenges. We aimed to evaluate the factors affecting clinical outcomes in patients undergoing radical surgery because of renal carcinoma and associated venous thrombosis.

MATERIALS AND METHODS

Hospital records were retrospectively reviewed to identify patients with renal carcinoma and associated venous thrombosis treated with radical surgery between 2006 and 2019. Preoperative, perioperative, and postoperative findings were analysed to determine the associations between clinical and survival outcomes. Overall and disease-free survival were analysed by the Kaplan-Meier method. Other associated prognostic variables were assessed using univariate and multivariate Cox regression analyses.

RESULTS

Thirty-three patients with renal carcinoma and associated venous thrombosis were enrolled for this study. There were 15 (45.4%) patients with level I, five (15.2%) with level II, eight (24.2%) with level III, and five (15.2%) with level IV venous thrombosis according to the Mayo Clinic classification system. The median follow-up was 35.6 months. In the univariate analysis, increased tumour size was associated with poor overall and disease-free survival. Preoperative clinic M1 disease was associated with poor overall survival. A high Mayo Clinic thrombus level was associated with poor disease-free survival. In the multivariate analysis, only tumour size and clinic M1 disease were independently correlated with poor overall survival. No independent statistically significant association was detected between thrombus level and survival outcomes.

CONCLUSIONS

Although the thrombus level was not associated with overall and disease-free survival, tumour size and clinic M1 disease were found to have an independent prognostic impact on overall survival.

Relationship between First Values of Red Cell Distribution Width, Mean Platelet Volume, Platelet Distribution Width, and Hospital Mortality in Acute Deep Venous Thrombosis

OBJECTIVE

To determine the relationship between red cell distribution width (RDW), mean platelet volume (MPV), platelet distribution width (PDW) values and mortality in acute deep vein thrombosis (DVT).

STUDY DESIGN

Descriptive study.

PLACE AND DURATION OF STUDY

Canakkale Onsekiz Mart University Health Practice and Research Hospital, Turkey, from 2015 to 2020.

METHODOLOGY

Hospitalised cases of acute DVT were detected. Discharged patients (externe group -EG), mortal course (mortality group - MG) and control group ( healthy persons without thrombosis - CG) were formed. Statistical significance of the first values of RDW, MPV and PDW between groups was evaluated. In addition, the difference between the groups was evaluated according to the age, gender, platelet count, and level of the thrombosis (proximal, distal).

RESULTS

There was a significant increase in RDW values between CG and EG (13.63 ± 1.37 vs. 15.97 ± 3.20; p=0.012), CG and MG (13.63 ± 1.37 vs. 17.85 ± 3.73; p=0.003). There was a significant increase in PDW values between CG and MG (16.78 ± 0.41 vs. 18.05 ± 1.07; p<0.001) and between EG and MG (16.98 ± 0.51 vs. 18.05 ± 1.07; p<0.001). There was no significant difference in other variables.

CONCLUSION

The results show that increased RDW values may be associated with deep venous thrombosis; and increased PDW values may be associated with mortality. Following RDW and PDW values, which are fast, inexpensive and widely available, can be useful as an early predictor of thrombosis and poor prognosis. Key Words: Red cell distribution width, Mean platelet volume, Platelet distribution width, Deep venous thrombosis, Predictor, Mortality, Poor prognosis.

A significant decrease in D-dimer concentration within one month of anticoagulation therapy as a predictor of both complete recanalization and risk of recurrence after initial pulmonary embolism

BACKGROUND

Abnormal D-dimer concentration measured during anticoagulation therapy (AT) or within one month of discontinuation, is associated with residual pulmonary obstruction (RPO) and risk of recurrent venous thromboembolism (VTE) after a first episode of pulmonary embolism (PE). We hypothesized that a significant decrease in D-dimer concentration within the first month of AT in patients with a first episode of PE may predict complete recanalization and a lower risk of recurrent VTE.

METHODS

One hundred and fifty patients with PE received anticoagulation therapy for three or six months when control computed tomography angiography (CTA) was performed. D-dimer levels were measured at admission and at 1-, 3- and/or 6-month follow-ups after the initial event. Clinical, echocardiographic, CTA and analytical data were collected. Predictive factors of RPO and predictive ability of D-dimer concentration at 1- and 6-month follow-ups were evaluated.

RESULTS

Of the 150 eligible patients, 33 (22%) had RPO in control CTA. Idiopathic PE, a delay of >7 days between symptom onset and diagnosis, and clinical PE severity determined by a s-PESI score ≥ 1 were associated with RPO. D-dimer concentration within a month of AT was significantly higher (823 [558-1259] vs 436 [243-934] ng/ml; p = 0.019) in patients with RPO; decrease (445 [35-1899] vs 912 [476-2858] ng/ml; p = 0.047) and decrease percentage (31.4% vs 76.6%; p < 0.005) in D-dimer concentrations were significantly lower. ROC analysis showed that decrease percentage in D-dimer concentration identified patients with complete recanalization (AUC 0.715, [95% CI, 0.611-0.819], p < 0.005). Decreases of >70% in initial D-dimer at 1-month (OR, 0.56, [95% CI, 0.45-0.70] p = 0.037) and 6-month follow-ups (OR, 0.31 [CI 95%, 0.15-0.66], p = 0.03) were associated with a lower risk of recurrent PE.

CONCLUSION

A significant decrease in D-dimer concentration within the first month of AT is associated with complete recanalization and could predict a lower risk of recurrent thrombosis after a first episode of PE.

Effectiveness of the Alfalfa App in Warfarin Therapy Management for Patients Undergoing Venous Thrombosis Prevention and Treatment: Cohort Study

BACKGROUND

Over the years, the internet has enabled considerable progress in the management of chronic diseases, especially hypertension and diabetes. It also provides novel opportunities in online anticoagulation management. Nevertheless, there is insufficient evidence regarding the effectiveness of online anticoagulation management.

OBJECTIVE

This study explored the effectiveness and safety of warfarin management via the Alfalfa app, so as to provide evidence in support of anticoagulant management through online services.

METHODS

In this retrospective, observational cohort study, 824 patients were included. In the offline group, patients went to the hospital clinic for warfarin management. In the Alfalfa app group, patients reported the dose of warfarin, current international normalized ratio (INR) value, and other related information through the Alfalfa app. Physicians or pharmacists used the app to adjust the dose of warfarin and determined the time for the next blood INR testing. Patients completed INR testing by point-of-care at home or hospital. The primary outcome of the study was the percentage of time in therapeutic range (TTR). Secondary outcomes included minor and major bleeding events, thrombotic events, warfarin-related emergency department visits, hospital admissions, and high INR values.

RESULTS

The TTR and percentage of INR values in the range were significantly higher in the Alfalfa app group than in the offline group (79.35% vs 52.38%, P<.001; 3314/4282, 77.39% vs 2005/4202, 47.72%, P<.001, respectively). Patients managed via the Alfalfa app had lower rates of subtherapeutic (172/4282, 4.02% vs 388/4202, 9.23%; P<.001), supratherapeutic (487/4282, 11.37% vs 882/4202, 20.99%; P<.001), and extreme subtherapeutic INR values (290/4282, 6.77% vs 910/4202, 21.66%; P<.001). Additionally, the Alfalfa app group had lower incidences of major bleeding (2/425, 0.5% vs 12/399, 3.0%; P=.005), warfarin-related emergency department visits (13/425, 3.1% vs 37/399, 9.3%; P<.001), and hospital admissions (1/425, 0.2% vs 12/399, 3.0%; P=.001) compared with the offline group. However, the Alfalfa app group had a higher incidence of minor bleeding than the offline group (45/425, 10.6% vs 20/399, 5.0%; P=.003). There were similar incidences in extreme supratherapeutic INR values (19/4282, 0.44% vs 17/4202, 0.40%; P=.78) and thromboembolic events (1/425, 0.2% vs 1/399, 0.3%; P=.53) between the two groups.

CONCLUSIONS

Warfarin management is superior via the Alfalfa app than via offline services in terms of major bleeding events, warfarin-related emergency department visits, and hospital admissions.

Association of hypoxia and mitochondrial damage associated molecular patterns in the pathogenesis of vein graft failure: a pilot study

Coronary artery bypass grafting (CABG) is the standard treatment modality in revascularization of the myocardium. However, the graft failure remains the major complication following CABG procedure. Involvement of mitochondrial damage-associated molecular patterns (mt-DAMPs) in the pathogenesis of vein-graft failure is largely unknown. Here, we investigated the expression of major protein-mt-DAMPs, cytochrome-C (Cyt-C), heat shock protein-60 (Hsp-60), mitochondrial transcription factor A (mtTFA), in the occluded graft and associated tissues, including distal left anterior descending (LAD), LAD adjacent to anastomosis, and left internal mammary artery (LIMA) in the microswine CABG model. The protein expression of peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α) was significantly decreased in the graft and LIMA, whereas the protein expression of hypoxia inducible factor-1 alpha (HIF-1α) and Cyt-C was decreased and that of mtTFA and Hsp60 was increased in all tissues compared to controls. There was no significant difference in the protein expression of citrate synthase, complex-1, and mitochondrial pyruvate dehydrogenase in the graft and associated tissues compared to control. Hypoxia in cultured smooth muscle cells (SMCs) significantly upregulated all mitochondrial biomarkers and mt-DAMPs compared to normoxia. The increased reactive oxygen species (ROS) content and compromised membrane integrity in the hypoxic SMCs correlated well with increased mt-DAMPs in the graft and associated tissues, suggesting a possible role of mt-DAMPs in the pathogenesis of graft failure. These findings suggest that the pathological signals elicited by mt-DAMPs could reveal targets for better therapeutic approaches and diagnostic strategies in the management of CABG graft failure.

Calf vein thrombosis outcomes comparing patients with and without cancer

Distal or calf deep vein thrombosis (DVT) are said to have low rates of propagation, embolization, and recurrence. The objective of this study was to determine outcomes among cancer patients with calf DVT compared to those without cancer. Consecutive patients with ultrasound confirmed acute calf DVT (3/1/2013-8/10/2019) were assessed for venous thromboembolism (VTE) recurrence and bleeding outcomes compared by cancer status. There were 830 patients with isolated calf DVT; 243 with cancer and 587 without cancer. Cancer patients were older (65.9 ± 11.4 vs. 62.0 ± 15.9 years; p = 0.006), with less frequent recent hospitalization (31.7% vs. 48.0%; p < 0.001), surgery (30.0% vs. 38.0%; p = 0.03), or trauma (3.7% vs. 19.9%; p < 0.001). The four most common cancers included hematologic malignancies (20.6%), lung (11.5%), gastrointestinal (10.3%), and ovarian/GYN (9.1%). Nearly half of patients had metastatic disease (43.8%) and 57% were receiving chemotherapy. VTE recurrence rates were similar for patients with (7.1%) and without cancer (4.0%; p = 0.105). Major bleeding (6.3% vs. 2.3%; p = 0.007) were greater for cancer patients while clinical relevant non major bleeding rates did not differ (7.1% vs. 4.6%; p = 0.159). In this retrospective analysis, cancer patients with calf DVT have similar rates of VTE recurrence but higher major bleeding outcomes compared to patients without cancer.

High risk of venous thromboembolism after orthopedic surgery in patients with thrombophilia

OBJECTIVE

This study aimed at evaluating the effect of thrombophilia on the risk of venous thromboembolism (VTE) in patients undergoing any type of orthopedic surgery.

BACKGROUND

Patients undergoing orthopedic surgery are at high risk for VTE. Although patients with thrombophilia have an increased risk of VTE, it is currently unclear whether there is a synergetic effect in patients with thrombophilia who undergo orthopedic surgery.

METHODS

Data from a large population-based case-control study (the Multiple Environmental and Genetic Assessment [MEGA] of risk factors for venous thrombosis study) were used. Odds ratios (ORs) with 95% confidence intervals (CIs), adjusted for age, sex, and body mass index (BMI) (ORadj) were calculated for patients undergoing any orthopedic intervention.

RESULTS

Of 4721 cases and 5638 controls, 263 cases and 94 controls underwent orthopedic surgery. Patients who had any orthopedic intervention in the year before the index date were at higher risk of VTE (ORadj 3.7; 95% CI, 2.9-4.8) than those who did not undergo any orthopedic surgery. There was an additionally increased risk in patients with factor V Leiden (OR 17.5, 95% CI, 4.1-73.6), non-O blood group (OR 11.2; 95% CI, 3.4-34.0), or elevated plasma levels of factor VIII (OR 18.6; 95% CI, 7.4-46.9) all relative to patients without these defects, not undergoing orthopedic surgery.

CONCLUSIONS

Patients with factor V Leiden, high levels of factor VIII, or blood group non-O were found to have a high risk of VTE after orthopedic surgery. Identification of these patients may enable individualized thromboprophylactic treatment to efficiently reduce VTE risk.

Hypercoagulability in Vestibular Schwannoma Surgery

OBJECTIVE

Patients with vestibular schwannoma who harbor a genetic predisposition for venous thromboembolism require special consideration when determining optimal therapeutic management. The primary objective of the current study was to provide recommendations on treatment of hypercoagulable patients with vestibular schwannoma through a case series and review of the literature.

PATIENTS

Two patients who underwent resection of vestibular schwannomas.

INTERVENTIONS

Surgical resection and diagnostic testing.

MAIN OUTCOME MEASURES

Postoperative venous thromboses.

RESULTS

One patient who underwent resection of vestibular schwannoma and suffered several postoperative thrombotic complications consistent with a clinical thrombophilia. One patient with known Factor V Leiden deficiency who underwent resection of vestibular schwannoma followed by postoperative chemoprophylaxis with a direct factor Xa inhibitor and experienced an uneventful postoperative course.

CONCLUSIONS

In patients with a known propensity for venous thromboembolism, the skull base surgeon should consider nonsurgical management. If the patient undergoes surgical resection, we recommend careful effort to minimize trauma to the sigmoid sinus. In addition, the surgeon may consider retrosigmoid or middle fossa approaches. Best practice recommendations include the use of pneumatic compression devices, early ambulation, and consideration of postoperative prophylactic anticoagulation in patients with a known genetic predisposition.

A critical analysis of 57 cases of Hughes-Stovin syndrome (HSS). A report by the HSS International Study Group (HSSISG)

BACKGROUND

Hughes-Stovin syndrome (HSS) is a systemic disease characterized by widespread vascular thrombosis and pulmonary vasculitis with serious morbidity and mortality. The HSS International Study Group is a multidisciplinary taskforce aiming to study HSS, in order to generate consensus recommendations regarding diagnosis and treatment.

METHODS

We included 57 published cases of HSS (43 males) and collected data regarding: clinical presentation, associated complications, hemoptysis severity, laboratory and computed tomography pulmonary angiography (CTPA) findings, treatment modalities and cause of death.

RESULTS

At initial presentation, DVT was observed in 29(33.3 %), thrombophlebitis in 3(5.3%), hemoptysis in 24(42.1%), and diplopia and seizures in 1 patient each. During the course of disease, DVT occurred in 48(84.2%) patients, and superficial thrombophlebitis was observed in 29(50.9%). Hemoptysis occurred in 53(93.0%) patients and was fatal in 12(21.1%). Pulmonary artery (PA) aneurysms (PAAs) were bilateral in 53(93%) patients. PAA were located within the main PA in 11(19.3%), lobar in 50(87.7%), interlobar in 13(22.8%) and segmental in 42(73.7%). Fatal outcomes were more common in patients with inferior vena cava thrombosis (p = 0.039) and ruptured PAAs (p < 0.001). Death was less common in patients treated with corticosteroids (p < 0.001), cyclophosphamide (p < 0.008), azathioprine (p < 0.008), combined immune modulators (p < 0.001). No patients had uveitis; 6(10.5%) had genital ulcers and 11(19.3%) had oral ulcers.

CONCLUSIONS

HSS may lead to serious morbidity and mortality if left untreated. PAAs, adherent in-situ thrombosis and aneurysmal wall enhancement are characteristic CTPA signs of HSS pulmonary vasculitis. Combined immune modulators contribute to favorable outcomes.

Hyperlipidaemic acute pancreatitis complicated with multiple deep vein thromboses and pulmonary embolism: a case successfully salvaged by radiologic intervention

Acute pancreatitis complicated with pulmonary embolism has been described in literature, however, hyperlipidaemic acute pancreatitis complicated with pulmonary embolism and deep vein thrombosis has rarely been reported. We reported here a rare case of hyperlipidaemic acute pancreatitis. Although he had undergone plasmapheresis and his TG level reduced to normal range with symptoms relieved, he developed pulmonary embolism and multiple deep vein thromboses. The patient was diagnosed early and successfully salvaged by interventional radiology and oral anticoagulants. The patient was a 51-year-old man, he experienced a sudden upper abdomen pain for 24 h before being admitted to a local hospital where diagnosis of acute pancreatitis was made, and he had no relief of the symptoms after treatment. The patient was a non-smoker and did not consume alcohol. He had no history of diabetes, gallstones or cholelithasis. After transferring to our unit, the patient was treated with plasmapheresis along with low molecular weight heparin, insulin, antibiotics and proton pump inhibitors and the abdomen pain was alleviated gradually. However, 8 days after admission, the patient developed a sudden chest tightness and shortness of breath. Examination revealed a high level of D-dimer (16700 ug/L), a computer tomography angiography of chest revealed pulmonary embolism. Urokinase was started intravenously. Pulmonary angiography and venography demonstrated pulmonary embolism and extensive lower limb deep vein thrombosis. Catheter directed thrombolysis and urokinase was initiated through catheter followed by an IVC filter implantation. Dyspnea of the patient got well with thrombolytic treatment and anticoagulation therapy. This is a rare case of hyperlipidaemic acute pancreatitis complicated pulmonary embolism and Deep vein thrombosis even after treated with plasmapheresis. The case we present here will aid in its early recognition, interventional radiology hence the prevention for this rare but catastrophic complication.

Portal vein surgical treatment on non-tumoral portal vein thrombosis in liver transplantation: Systematic Review and Meta-Analysis

Non-tumoral portal vein thrombosis (PVT) is associated with higher morbidity and mortality in liver transplantation (LT). In this study, we aimed to evaluate the impact of PVT in LT outcomes and analyze the types of surgical techniques used for dealing with PVT during LT. A systematic review was conducted in Cochrane, MEDLINE, and EMBASE databases, selecting articles from January 1990 to December 2019. The MESH-terms used were ("Portal Vein"[Mesh] AND "Thrombosis"[Mesh] NOT "Neoplasms"[Mesh]) AND ("Liver Transplantation"[Mesh]). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) recommendation was used, and meta-analysis was performed with Review Manager Version 5.3 software. A total of 1,638 articles were initially found: 488 in PubMed, 289 in Cochrane Library, and 861 in EMBASE, from which 27 were eventually selected for the meta-analysis. Surgery time of LT in patients with PVT was longer than in patients without LT (p<0.0001). Intraoperative red blood cell (p<0.00001), fresh frozen plasma (p=0.01), and platelets (p=0.03) transfusions during LT were higher in patients with PVT. One-year (odds ratio [OR] 1.17; p=0.002) and 5-year (OR 1.12; p=0.01) patient survival after LT was worse in the PVT group. Total occlusive PVT presented higher mortality (OR 3.70; p=0.00009) and rethrombosis rates (OR 3.47 [1.18-10.21]; p=0.02). PVT Yerdel III/IV classification exhibited worse 1-year [2.04 (1.21-3.42); p=0.007] and 5-year [0.98 (0.59-1.62); p=0.93] patient survival. Thrombectomy with primary anastomosis was associated with better outcomes. LT in patients with non-tumoral PVT demands more surgical time, needs more intraoperative transfusion, and presents worse 1- and 5-year patient survival. Total occlusive PVT and Yerdel III/IV PVT classification were associated with higher mortality. (PROSPERO, registration number: CRD42020132915).

Practice guidance for diagnosis and treatment of pancreatitis-related splanchnic vein thrombosis (Shenyang, 2020)

Splanchnic vein thrombosis is a severe complication of pancreatitis. To date, no consensus over the management of pancreatitis-related splanchnic vein thrombosis has been established. Based on the consensus of multidisciplinary experts, this practice guidance systematically reviewed the epidemiology, anatomy, pathophysiology, risk assessment and clinical presentations of splanchnic vein thrombosis, and formulated a diagnosis and treatment strategy for providing guidance in clinical practice for this disease.

Risk of infections and cardiovascular and venous thromboembolic events associated with JAK inhibitors in rheumatoid arthritis: protocols of two systematic reviews and network meta-analyses

INTRODUCTION

Janus kinases (JAK) inhibitors demonstrated to be effective in the treatment of adult patients with moderate-to-severe active rheumatoid arthritis (RA) but have been associated with serious cardiovascular and serious events. Two systematic reviews and network meta-analyses will be carried aiming to compare the relative safety of the different JAK inhibitors with regard to the risk of (1) cardiovascular and thromboembolic events and (2) serious infections in patients with RA.

METHODS AND ANALYSIS

PUBMED, Embase, Cochrane Controlled Register of Trials and ClinicalTrials.gov will be searched in order to identify randomised controlled trials evaluating the efficacy and safety of JAK inhibitors in patients with RA. The following events will be assessed: (1) any cardiovascular event; major adverse cardiovascular events and venous thromboembolism and (2) any infection; serious infections; herpes zoster infection and tuberculosis. Search terms will comprise RA and drugs names, including the thesaurus terms and the International Nonproprietary Names. The assessment of the methodological quality of the included studies will be performed through the RoB 2 tool: a revised Cochrane risk of bias tool for randomised trials. Network meta-analyses will be performed using STATA V.13.0. For each outcome, treatments will be ranked according to the probability of being the safest (best) alternative using the surface under the cumulative ranking curve.

ETHICS AND DISSEMINATION

Ethical approval is not required as no primary data are collected. This systematic review will be disseminated through peer-reviewed publications and at conference meetings.

[Progress in interferon: A treatment of Behcet syndrome]

Behcet syndrome (BS) is a chronic systemic inflammatory disorder involving vessels of all sizes, characterized by relapsing episodes of oral and/or genital ulcers, as well as skin lesions. Ocular, vascular, gastrointestinal, neurological system involvement can cause significant morbidity and mortality. Glucocorticoids and immunosuppressants are the cornerstones for the management of BS. Biologic agents has been recommended for severe and/or refractory BS. Interferon-α (IFN-α) had multiple biological effects, such as antiviral and antiproliferative, that could regulate both innate and adaptive immunity in BS. Growing evidence showed the efficacy of IFN-α in severe and/or refractory BS. Many studies have demonstrated that IFN-α has comparable effectiveness and tolerance profiles as anti-tumor necrosis factor (TNF) agents for Behcet's uveitis with a much lower cost and steroid-and immunosuppressant-sparing effects. IFN-α has been recommended as second-line therapy for ocular involvement of BS in EULAR (The European League Against Rheumatism) 2018. IFN-α also improves mucocutaneous lesions in BS with the dosage from 3 to 9-12 million IU three times per week. A few cases indicated the therapeutic potential of IFN-α in intestinal BS. As a new trial of IFN-α in vascular BS (VBS), a recent study revealed the lower relapse rate and higher recanalization rate with IFN-α in lower extremity deep vein thrombosis (DVT). Another two case reports presented the efficacy of IFN-α in pulmonary artery involvement in BS. Also, case reports have shown successful treatment in refractory neurological involvement. There are two subtypes of IFN-α commonly used in autoimmune diseases, named IFN-α2a and IFN-α2b. IFN-α2a seemed more effective than IFN-α2b, especially in ocular and mucocutaneous involvement of BS. Side effects of IFN-α are dose-dependent and not severe. The most frequent side effects are flu-like syndrome, mild leukopenia and alopecia. Considering the potential risk of tuberculosis (TB) and hepatitis B virus (HBV) reactivation of TNF-α inhibitors, IFN-α is safe due to its anti-HBV effect and protective effect on TB. In conclusion, IFN-α is a promising choice for severe and/or refractory BS patients, especially for those who are intolerant or contraindicant to other biological agents, such as TNF inhibitors. Further prospective controlled studies are warranted to confirm the efficacy and safety of IFN-α in BS.

Microengineered Human Vein-Chip Recreates Venous Valve Architecture and Its Contribution to Thrombosis

Deep vein thrombosis (DVT) and its consequences are lethal, but current models cannot completely dissect its determinants-endothelium, flow, and blood constituents-together called Virchow's triad. Most models for studying DVT forego assessment of venous valves that serve as the primary sites of DVT formation. Therefore, the knowledge of DVT formed at the venous cusps has remained obscure due to lack of experimental models. Here, organ-on-chip methodology is leveraged to create a Vein-Chip platform integrating fully vascularized venous valves and its hemodynamic, as seen in vivo. These Vein-Chips reveal that vascular endothelium of valve cusps adapts to the locally disturbed microenvironment by expressing a different phenotype from the regions of uniform flow. This spatial adaptation of endothelial function recreated on the in vitro Vein-Chip platform is shown to protect the vein from thrombosis from disturbed flow in valves, but interestingly, cytokine stimulation reverses the effect and switches the valve endothelium to becoming prothrombotic. The platform eventually modulates the three factors of Virchow's triad and provides a systematic approach to investigate the determinants of fibrin and platelet dynamics of DVT. Therefore, this Vein-Chip offers a new preclinical approach to study venous pathophysiology and show effects of antithrombotic drug treatment.

A comparative analysis of the efficacy and safety of therapeutic interventions in phlegmasia cerulea dolens

OBJECTIVE

Present an institution's experience in management of phlegmasia cerulea dolens (PCD) with a review of the literature.

METHODS

Beaumont Health's electronic record database was queried between July 2009 and November 2019 for inpatients with PCD. A comprehensive chart review was performed to verify the accuracy of the diagnosis and extract relevant parameters. Medians and proportions are reported.

RESULTS

22 patients met the criteria for PCD. 59% females. Median age 65 years (interquartile range [IQR] 22). Obesity was present in 45% of patients. 18 patients underwent either a single modality (55.5%) or a multimodality therapeutic approach (44.5%). Limb amputation was required in a third of patients who underwent catheter-directed thrombolysis or percutaneous thrombectomy alone. Death was highest after percutaneous thrombectomy alone (66%) followed by pharmacomechanical catheter-directed thrombolysis alone (50%).

CONCLUSION

Percutaneous interventions have become the mainstay in management of PCD as demonstrated in this large retrospective analysis and supported by literature review.

Deep vein thrombosis and brain metastases. Case report and systematic review

Secondary brain tumours, also known as brain metastasis, are a group of neoplasias which constitute the most frequent type of brain tumour in adults. Up to 20% patients with brain metastasis present venous thromboembolism (VTE). The management of VTE in these patients is complicated by multiple factors including intracranial haemorrhage, among others. We evaluated the case fatality rate (the proportion of patients who die due to a particular condition) of haemorrhage and recurrent VTE in patients with deep vein thrombosis (DVT) and brain metastasis to compare the risk/benefits of anticoagulant treatment. We also describe a clinical case and a systematic review of the literature on the management of anticoagulant treatment in patients with brain metastases and DVT. The principal objective of this review was to clarify the main questions about the management of this type of patient based on a clinical case.

The molecular basis for the prothrombotic state in sickle cell disease

The genetic and molecular basis of sickle cell disease (SCD) has long since been characterized but the pathophysiological basis is not entirely defined. How a red cell hemolytic disorder initiates inflammation, endothelial dysfunction, coagulation activation and eventually leads to vascular thrombosis, is yet to be elucidated. Recent evidence has demonstrated a high frequency of unprovoked/recurrent venous thromboembolism (VTE) in SCD, with an increased risk of mortality among patients with a history of VTE. Here, we thoroughly review the molecular basis for the prothrombotic state in SCD, specifically highlighting emerging evidence for activation of overlapping inflammation and coagulation pathways, that predispose to venous thromboembolism. We share perspectives in managing venous thrombosis in SCD, highlighting innovative therapies with the potential to influence the clinical course of disease and reduce thrombotic risk, while maintaining an acceptable safety profile.

Tranexamic acid reduces blood cost in long-segment spinal fusion surgery: A randomized controlled study protocol

OBJECTIVE

Long-segment spinal fusion surgery was associated with substantial perioperative blood loss which may increase hospitalization expenses and mortality rates. Substantial studies have reported that tranexamic acid (TXA) could reduce blood products and cost after joint arthroplasty surgery. However, there still exists controversy regarding the efficacy of TXA in long-segment spinal fusion surgery. We performed this protocol to design a randomized controlled study to evaluate the efficacy of TXA in decreasing transfusion rate of allogeneic blood products and transfusion cost in degenerative lumbar scoliosis patients.

METHODS

This study was carried out as a double-blinded, randomized clinical trial on patients with degenerative lumbar scoliosis who prepared for long-segment spinal fusion surgery from December 2018 to December 2019. It was authorized via the Institutional Review Committee in Southwest Medical University (ky2019225). Eighty patients were divided randomly into 2 groups (Experimental group = 40, control group = 40). The patients in the experimental group received 1000 mg of TXA mixed in 100 mL normal saline as a single dose intravenously over 20 minutes before the skin incision was made. Control group received equivalent normal saline without TXA. Primary outcomes included total blood loss, estimated intraoperative blood loss, hematocrit and hemoglobin decline, postoperative drain amount, intra-/postoperative allogeneic transfusion amount and rate, and total transfusion cost. Secondary outcomes included surgical time, thrombotic complications including deep vein thrombosis and pulmonary embolism. All the needed analyses were implemented through utilizing SPSS for Windows Version 20.0.

RESULTS

Table showed the relevant clinical outcomes between experimental group and control group.

CONCLUSION

We hypothesized that TXA was effective and safe in reducing blood transfusion and cost in long-segment spinal fusion surgery.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5854).

Hypervitaminosis D and Cortical Venous Thrombosis; An Unusual Presentation

Hypervitaminosis D is rare but potentially serious condition. It occurs most commonly due to excess doses of vitamin D supplementation, most commonly intramuscular. Here we report a case of iatrogenic hypervitaminosis D who presented with altered sensorium, cortical venous thrombosis and acute renal failure.

May Thurner syndrome: description of a case with unusual clinical onset

May-Thurner syndrome (MTS) is a congenital vascular alteration that is part of a restricted category of very rare vascular syndromes that have in common the compression of an arterial or venous vessel. MTS, first described in 1957, is due to compression of the left common iliac vein against the lumbar spine by the adjacent common iliac artery. It can cause chronic thrombosis of the left lower limb and can give edema, pain, claudication, thrombophlebitis, and, in severe cases, pulmonary embolism. Color Doppler and duplex Doppler ultrasound allow us to easily locate the deep vein thrombosis, to measure its extension, and to highlight the vascular changes typical of MTS: compression and consequent hypertension of the left common iliac vein. The therapy depends on the degree of venous stasis and on the presence of venous thrombosis; generally, it consists of the administration of short- or long-term anticoagulant and thrombolytic drugs. In cases of severe stenosis of the left common iliac vein, the first-choice treatment consists of positioning a vascular stent, which resolves compression and significantly reduces chronic thrombotic episodes. We describe a case of MTS with an unusual clinical onset with pulmonary embolism.

Results of surgical treatment of inferior vena cava tumor thrombi in renal cell carcinoma

INTRODUCTION

Thrombosis of inferior vena cava (IVC) is an important complication amongst oncological patients. Tumor thrombus of IVC is characteristic for patients with renal cell carcinoma, occurring in 1018%. The aim of the work is to analyze of surgical treatment in patients with cancer thrombosis of inferior vena cava in kidney cancer.

METHODS

Between 2010 and 2019 we treated 32 patients with kidney cancer complicated by thrombotic infiltration of the inferior vena cava. According to Nesbitt classification the levels of thrombotic infiltration of the inferior vena cava were: I-8 (25%), II-14 (43.8%), III-6 (18.8%), and IV-4 (12.5%). Nephrectomy with thrombectomy of the cancer thrombus in the inferior vena cava was performed in all patients. In addition to laparotomy, sternotomy was approached in 4 patients with Nesbitt IV and in 2 patients with Nesbitt III.

RESULTS

Primary suture of IVC was performed in 26 patients; angioplasty of IVC was performed in 4 patients; and resection of IVC with replacement using a polytetrafluoroethylene interposition graft was done in 2 patients. Radical surgical treatment was performed in 27 (84.3%) patients, and palliative in 5 (15.6%) patients. In the postoperative period, 1 (3.1%) patient (Nesbitt IV) died of cardiac failure during hospitalisation. Two-year survival was observed in 75% of the cases.

CONCLUSION

Tumorous infiltration of IVC is associated with a high potential for tumour embolisation to the lungs, leading to the formation of multiple metastases and spreading of the underlying disease. Postoperative comfort is improved considerably after nephrectomy of the affected kidney and removal of the tumour thrombus, including IVC resection as appropriate, and when combined with oncological treatment, the survival rate is increased significantly, as well.

Diagnostic challenges in non-cirrhotic portal hypertension - porto sinusoidal vascular disease

Non-cirrhotic portal hypertension consists of a group of diseases characterized by signs and complications of portal hypertension, which differ from cirrhosis through histological alterations, hemodynamic characterization and, clinical outcome. Because of the similarities in clinical presentation and imaging signs, frequently these patients, and particularly those with porto-sinusoidal vascular disease (PSVD), are misdiagnosed as having liver cirrhosis and thus raising difficulties in their diagnosis. The most challenging differentiation to be considered is between PSVD and cirrhosis and, although not pathognomonic, liver biopsy is still the standard of diagnosis. Although they still require extended validation before being broadly used, new non-invasive methods for the diagnosis of porto-sinusoidal vascular disease, like transient elastography, contrast-enhanced ultrasound or metabolomic profiling, have shown promising results. Another issue is the differentiation between PSVD and chronic extrahepatic portal vein obstruction, especially now when it is known that 40% of patients suffering from PSVD develop portal vein thrombosis. In this particular case, once the portal vein thrombosis occurred, the diagnosis of PSVD is impossible according to the current guidelines. Moreover, so far, the differentiation between PSVD and sinusoidal obstruction syndrome has not been clear so far in particular circumstances. In this review we highlighted the diagnostic challenges regarding the PSVD, as well as the current techniques used in the evaluation of these patients.

Meta-Analysis of the Role of Intermittent Pneumatic Compression of the Lower Limbs to Prevent Venous Thromboembolism in Critically Ill Patients

Critically ill patients (patients treated in a medical or surgical intensive care unit) are at high risk of venous thromboembolism (VTE) development (deep vein thrombosis [DVT] and/or pulmonary embolism). Multiple thromboprophylaxis strategies have been used for the prevention of VTE in this population with various outcomes. Therefore, we aimed to evaluate the efficacy of intermittent pneumatic compression (IPC) prophylaxis in the lower limb compared with no treatment, anticoagulant use, or their combinations in reducing risk. A comprehensive electronic database search was conducted for all randomized clinical trials (RCTs) comparing the clinical outcomes of IPC versus anticoagulants or no treatment or their combinations for the prevention of VTE for critically ill patients. The primary outcome was VTE. The secondary outcome was DVT. We performed a Bayesian network meta-analysis to calculate odds ratios (ORs) and 95% credible intervals (CrIs). We included 5 RCTs with 3133 total patients, represented by a mean age of 49.61 ± 18 years, while 60.28% were male. There was a significant reduction of the primary outcome (incidence of VTE events) when no treatment was compared with IPC (OR = 0.36; 95% CrI = 0.18-0.71), anticoagulation alone (OR = 0.30; 95% CrI = 0.12-0.68), or anticoagulation with IPC (OR = 0.34; 95% CrI = 0.13-0.81). In addition, there was a significant reduction in DVT when no treatment was compared with IPC (OR = 0.45; 95% CrI = 0.21-0.9), anticoagulation alone (OR = 0.16; 95% CrI = 0.03-0.66), or anticoagulation with IPC (OR = 0.18; 95% CrI = 0.03-0.84). However, there were no significant differences between other comparisons (IPC vs anticoagulation alone, anticoagulation alone vs anticoagulation with IPC, or anticoagulation with IPC vs IPC alone) regarding VTE or DVT incidence. Among critically ill patients, IPC alone, anticoagulation alone, and IPC with anticoagulation were associated with a significant reduction of VTE and DVT incidence compared with no treatment. However, there was no significant difference between these modalities when compared together. Therefore, further larger studies comparing those different thromboprophylaxis modalities and their combinations are needed to provide more robust results for future clinical recommendations.

The impact of ABO blood type on the prevalence of portal vein thrombosis in patients with advanced chronic liver disease

BACKGROUND AND AIMS

Non-O blood type (BT) is a risk factor for thromboses, which has been attributed to its effects on von Willebrand factor (VWF)/factor VIII (FVIII) levels. Although high VWF/FVIII may be risk factors for portal vein thrombosis (PVT) in patients with advanced chronic liver disease (ACLD), the impact of BT on PVT is unknown. We aimed to assess (I) whether non-O-BT is a risk factor for PVT and (II) whether non-O-BT impacts VWF/factor VIII in patients with ACLD.

METHODS

Retrospective analysis comprising two cohorts: (I) "US" including all adult liver transplantations in the US in the MELD era and (II) "Vienna" comprising patients with a hepatic venous pressure gradient (HVPG) ≥6 mmHg.

RESULTS

(I) The "US cohort" included 84 947 patients (non-O: 55.43%). The prevalence of PVT at the time of listing (4.37% vs 4.56%; P = .1762) and at liver transplantation (9.56% vs 9.33%; P = .2546) was similar in patients with O- and non-O-BT. (II) 411 patients were included in the "Vienna cohort" (non-O: 64%). Mean HVPG was 18(9) mmHg and 90% had an HVPG ≥10 mmHg. Patients with non-O-BT had slightly increased VWF levels (318(164)% vs 309(176)%; P = .048; increase of 23.8%-23.9% in adjusted analyses), but this difference was driven by patients with less advanced disease. However, non-O-BT explained only 1% of the variation in VWF and had no effect on FVIII.

CONCLUSIONS

Although non-O-BT impacts VWF in patients with early stage ACLD, its contribution to VWF variation is considerably smaller than in the general population. Moreover, non-O-BT had no impact on FVIII. These findings may explain the absence of an association between non-O-BT and PVT in patients with advanced cirrhosis.

Development of a standardized definition of pulmonary embolism-related death: A cross-sectional survey of international thrombosis experts

INTRODUCTION

Pulmonary embolism (PE)-related death is often part of the primary outcome in venous thromboembolism (VTE) studies. The Scientific and Standardization Committee (SSC) of the International Society on Thrombosis and Haemostasis developed a definition for PE-related death and classification of the cause of death. The present survey evaluated a preliminary version of this definition and classification.

METHODS

Sixty-nine VTE experts from nine countries were invited for a cross-sectional online survey on January 15, 2019, including multiple-choice and open-ended questions on a seven-subcategory classification of the cause of death. Descriptive statistics were used to describe the results; qualitative comments were summarized.

RESULTS

Forty of 69 (58%) invitees completed the survey. All respondents agreed that guidance on classification of the cause of death in VTE studies is required. There was high agreement on the proposal (median overall score, 6; interquartile range, 6-7; scale from 1 [poor] to 7 [excellent]). All respondents approved the wording and content of the seven subcategories, except for one disagreeing vote for two subcategories (A3: "PE is not objectively confirmed, but is most likely the main cause of death" and C1: "Another cause of death is more likely than PE but has not been objectively confirmed"). Suggestions for improvement mainly concerned the extensiveness of the criteria and clinical situations described to define the cause of death.

CONCLUSION

Acceptance of the proposal was excellent. Suggestions for improvement were incorporated in the SSC communication on the definition of PE-related death and classification of the cause of death in VTE studies.

A Single-Centre Feasibility Randomised Controlled Trial Comparing the Incidence of Asymptomatic and Symptomatic Deep Vein Thrombosis Between a Neuromuscular Electrostimulation Device and Thromboembolism Deterrent Stockings in Post-Operative Patients Recovering From Elective Total Hip Replacement Surgery

BACKGROUND

Total hip replacement is recognised as a major risk factor for deep vein thrombosis (DVT). The aim of this study was to investigate the feasibility of using a novel neuromuscular electrical stimulation device (NMES) for DVT prevention in patients recovering from elective hip replacement surgery.

METHODS

Twenty-eight patients undergoing total hip replacement were randomised to receive postoperative treatment with either the NMES device or compression stockings continually from post-surgery until discharge (day 4). The primary outcome measure was the presence of symptomatic or asymptomatic DVT at 48 hours post-surgery and on the day of discharge from hip replacement surgery, as assessed by Duplex ultrasound. Secondary outcomes included hemodynamic responses to the devices, lower limb oedema, sit-to-stand and timed-up-and-go (TUG) scores, and hip range of motion.

RESULTS

In the compression stockings group, two cases of asymptomatic DVT were identified by Duplex ultrasound at 48 hours post-surgery. No cases were found in the NMES group. Patients in the NMES group demonstrated a general trend of a decrease in leg volume from post-surgery to discharge, whereas leg volume largely remained static for the compression stockings group. In addition, positive hemodynamic effects were found in favour of the NMES group in the non-operated leg. The change in TUG scores also favoured the NMES group (NMES: 150 ± 152%, compression stockings: 363 ± 257% (p=0.03)), whereas no differences in sit-to-stand scores or hip range of motion were observed.

CONCLUSIONS

This study supports the feasibility of NMES as an alternative mechanical prophylaxis worn in the postoperative phase until discharge and provides important findings for clinicians considering novel mechanical prophylaxis options.