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Nava Y Hurtado F, Monzon Manzano E, Viana-Huete V, Triana Junco P, Alvarez-Roman MT, Arias-Salgado EG, Butta N, Lopez Gutierrez JC. Assessing coagulopathy and endothelial dysfunction in pediatric venous malformation: A thromboelastometry and syndecan-1 study. Pediatr Blood Cancer 2024; 71:e30915. [PMID: 38369689 DOI: 10.1002/pbc.30915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/15/2024] [Accepted: 01/28/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVE The occurrence of unpredictable pain crises are the principal determinant of the quality of life for patients with venous malformations (VM). A definite coagulation phenomenon, characterized by an increase in D-dimer levels and the presence of phleboliths within the malformation, has been previously reported. By applying Virchow's triad and evaluating intralesional samples, our objective is to delineate the coagulation profile and the extent of endothelial dysfunction within the malformation. METHODS With the authorization of the Ethics Committee, a research project was undertaken on intralesional and extralesional blood samples from 30 pediatric patients afflicted with spongiform VM. Thromboelastometry analyses were performed using ROTEM Sigma, and the concentration of syndecan-1 was determined by ELISA. RESULTS In the ROTEM analyses, the A5, A10, and maximum clot firmness (MCF) values were below the established reference ranges in the intralesional samples in both the EXTEM and INTEM assays, indicating that intralesional clots had significant instability. Furthermore, during the investigation of the delayed fibrinolysis phase using recombinant tissue plasminogen activator (rtPA) in EXTEM analysis, widespread hyperfibrinolysis was observed intralesional. Additionally, analysis of syndecan-1 showed significant differences between extralesional and intralesional levels (p < .026) and controls (p < .03), suggesting differences in the state of endothelium. CONCLUSIONS For the first time, we developed a comprehensive understanding of the coagulopathic profile of VM and the role of endothelial dysfunction in its pathogenesis. These findings will enable the implementation of targeted therapies based on the individual coagulation profiles.
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Affiliation(s)
| | - Elena Monzon Manzano
- Department of Haematology, Hospital Universitario La Paz, Madrid, Spain
- IdiPAZ, Madrid, Spain
| | - Vanesa Viana-Huete
- Department of Health Sciences, Universidad Europea de Madrid, Madrid, Spain
| | - Paloma Triana Junco
- Department of Paediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | | | - Elena G Arias-Salgado
- Department of Haematology, Hospital Universitario La Paz, Madrid, Spain
- IdiPAZ, Madrid, Spain
| | - Nora Butta
- Department of Haematology, Hospital Universitario La Paz, Madrid, Spain
- IdiPAZ, Madrid, Spain
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Crary SE, Mack JM. Anticoagulation and vascular anomalies. Res Pract Thromb Haemost 2024; 8:102402. [PMID: 38694837 PMCID: PMC11060946 DOI: 10.1016/j.rpth.2024.102402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 05/04/2024] Open
Abstract
A State of the Art lecture titled "Anticoagulation and Vascular Anomalies" was presented at the International Society on Thrombosis and Haemostasis (ISTH) Congress in 2023. Vascular anomalies have been classified by the International Society for the Study of Vascular Anomalies into vascular tumors and vascular malformations. Although some vascular tumors, such as tufted angioma and kaposiform hemangioendothelioma, and other vascular malformations can present with coagulation aberrancies, these are not generally managed with anticoagulation. A subclassification of vascular malformations includes slow-flow vascular malformations. It is this subgroup specifically that has a high risk of venous thromboembolism (VTE) and morbidity associated with coagulopathy that may be present. In these select cases, anticoagulation may be indicated to reduce the risk of VTE, treat VTE, or manage localized thrombosis in the malformation that causes significant pain and reduced quality of life. There are established risk factors for VTE in these patients that will be reviewed. Finally, we summarize relevant new data on this topic presented during the 2023 ISTH Congress.
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Affiliation(s)
- Shelley E. Crary
- Division of Pediatric Hematology-Oncology, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Arkansas, USA
| | - Joana M. Mack
- Division of Pediatric Hematology-Oncology, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Arkansas, USA
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Ramanujam V, DiMaria S, Varma V. Thromboelastography in the Perioperative Period: A Literature Review. Cureus 2023; 15:e39407. [PMID: 37362492 PMCID: PMC10287184 DOI: 10.7759/cureus.39407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
Assessing coagulation status is essential for prompt intervention to reduce morbidity and mortality related to bleeding and thrombotic complications during the perioperative period. Traditional coagulation tests such as platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), and activated clotting time (ACT) provide only static evaluation. These tests are not designed for assessment of dynamically changing coagulation conditions during the perioperative time. However, viscoelastic coagulation testing such as thromboelastography (TEG) produces a rapid numerical and graphical representation that helps to detect and direct targeted hemostatic therapy. Searching the literature through PubMed, Medline, Ovid, CINAHL, and ClinicalTrials.gov we retrieved 210 studies, which represent the use of TEG in the perioperative period. The included studies were categorized under various settings such as trauma, obstetrics, orthopedics, intensive care unit (ICU), cardiovascular, transplant, and miscellaneous scenarios. TEG showed promising results in trauma surgeries in predicting mortality, hypercoagulability, and bleeding even when it was compared to conventional methods. TEG was also useful in monitoring anticoagulant therapy in orthopedic and obstetric surgeries; however, its role in predicting thrombotic events, hypercoagulability, or complications was questionable. In ICU patients, it showed promising results, especially in the prediction or improvement of sepsis, coagulopathy, thrombotic events, ICU duration, hospital stay, and ventilator duration. TEG parameters effectively predicted hypercoagulation in transplant surgeries. Regarding cardiovascular surgeries, they were effective in the prediction of the need for blood products, coagulopathy, thrombotic events, and monitoring anticoagulation therapy. More randomized clinical trials comparing TEG parameters with standardized tools are needed to produce robust results to standardize its use in different perioperative settings.
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Affiliation(s)
- Vendhan Ramanujam
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| | - Stephen DiMaria
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| | - Vivek Varma
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
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Chen JH, Zhou H, Zhang Q, Wang H, Hidig SM, Chen XY, Feng S. Diagnostic value of mean platelet volume combined with thromboelastography for coagulation state after total knee arthroplasty. Clin Hemorheol Microcirc 2023; 84:321-331. [PMID: 37212090 DOI: 10.3233/ch-231802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND The main objective of this study was to predict the status of blood and the occurrence of lower limb deep vein thrombosis (DVT) after total knee arthroplasty(TKA) by means of mean platelet volume (MPV) combined with thromboelastography (TEG). METHODS We collected 180 patients who underwent unilateral total knee arthroplasty between May 2015 and March 2022, and the patients were divided into DVT group and control group according to whole-leg ultrasonography on the seventh postoperative day. Blood count and TEG were performed on the day before surgery, the first day after surgery and the seventh day respectively. Multifactorial analysis was used to investigate whether the relevant parameters were independent predictors of DVT after TKA. RESULTS MPV has the strongest correlation with the maximum amplitude (MA), followed by alpha-angle; MPV and alpha-angle on the first postoperative day are independent predictors of DVT. MPV in patients with thrombosis tends to rise and then fall in the perioperative period. The optimal threshold for MPV to predict thrombosis is 10.85 fL and the area under the ROC curve is 0.694, The area under the ROC curve increases to 0.815 using MPV combined with alpha-angle. In addition, MA, α-angle, composite coagulation index (CI) and MPV were all statistically higher in the DVT group than in the control group (p < 0.001). CONCLUSION MPV is a predictor of DVT after TKA. It can reflect the hypercoagulable state of blood after surgery; Combination of MPV and alpha-angle on the first day after surgery in patients with TKA improves predictive power of DVT.
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Affiliation(s)
- Jia-Hao Chen
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Hang Zhou
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Qiang Zhang
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Hu Wang
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Sakarie Mustafe Hidig
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Xiang-Yang Chen
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Shuo Feng
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
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Mack JM, Crary SE. How we approach coagulopathy with vascular anomalies. Pediatr Blood Cancer 2022; 69 Suppl 3:e29353. [PMID: 36070211 DOI: 10.1002/pbc.29353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 08/14/2021] [Accepted: 08/31/2021] [Indexed: 01/19/2023]
Abstract
Some vascular anomalies can present with challenging hematologic aberrations. Kaposiform hemangioendothelioma (KHE) may be complicated with Kasabach-Merritt phenomenon (KMP) and stagnant blood flow in slow-flow malformations can promote activation and consumption of coagulation factors, which results in bleeding and clotting known as localized intravascular coagulopathy (LIC). These patients can experience significant morbidity secondary to pain due to thrombosis and are at higher risk of hematologic complications during surgical procedures. No standard of care has been established to prevent or manage these complications. This review focuses on the management of coagulopathy in children and adults with vascular anomalies.
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Affiliation(s)
- Joana M Mack
- Department of Pediatrics, Division of Hematology/Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Shelley E Crary
- Department of Pediatrics, Division of Hematology/Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Arkansas Children's Hospital, Little Rock, Arkansas, USA
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Dorrity J, Mack J, Wong K, Richter GT. Multimodality Treatment of Vascular Anomalies of The Head And Neck. J Oral Pathol Med 2022; 51:860-871. [PMID: 35674677 DOI: 10.1111/jop.13322] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/03/2022] [Indexed: 11/27/2022]
Abstract
Vascular anomalies affect up to 5% of children with the majority affecting the head and neck. They present at different ages as a wide variety of lesions. Careful evaluation with history, physcial examination and imaging assist in the proper diagnosis. Depending on the condition, treatment options for vascular anomalies include topical therapy, selective photothermolysis, sclerotherapy, embolization, surgical excision and targeted systemic therapy. Staged multimodal therapeutic regimens have proven to best control disease and allow for preservation of function and aesthetics. The timing, sequence and combination of therapies is best determined by a multidisciplinary vascular anomalies team. Patients and families need to be counseled on anticipated positive outcomes following a protracted course of treatment for the majority of vascular anomalies.
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Affiliation(s)
- Jeffrey Dorrity
- University of Arkansas for Medical Sciences Department of Otolaryngology-Head and Neck Surgery, 4801 W Markham, Little Rock, AR
| | - Joana Mack
- University of Arkansas for Medical Sciences Department of Otolaryngology-Head and Neck Surgery, 4801 W Markham, Little Rock, AR
| | - Kevin Wong
- University of Arkansas for Medical Sciences Department of Otolaryngology-Head and Neck Surgery, 4801 W Markham, Little Rock, AR
| | - Gresham T Richter
- University of Arkansas for Medical Sciences Department of Otolaryngology-Head and Neck Surgery, 4801 W Markham, Little Rock, AR
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Kim Y, Patel SS, McElroy IE, DeCarlo C, Bellomo TR, Majumdar M, Lella SK, Mohebali J, Dua A. A Systematic Review of Thromboelastography Utilization in Vascular and Endovascular Surgery. J Vasc Surg 2021; 75:1107-1115. [PMID: 34788649 DOI: 10.1016/j.jvs.2021.11.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 11/08/2021] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Thromboelastography (TEG) is diagnostic modality that analyzes real-time blood coagulation parameters. Clinically, TEG primarily allows for directed blood component resuscitation among patients with acute blood loss and coagulopathy. The utilization of TEG has been widely adopted in among other surgical specialties; however, its use in vascular surgery is less prominent. We aimed to provide an up-to-date review of TEG utilization in vascular and endovascular surgery. METHODS Using PRISMA guidelines, a literature review with the Medical Subject Headings (MeSH) terms "TEG and arterial events", "TEG and vascular surgery", "TEG and vascular", "TEG and endovascular surgery", "TEG and endovascular", "TEG and peripheral artery disease", "TEG and prediction of arterial events", "TEG and prediction of complications ", "TEG and prediction of thrombosis", "TEG and prediction of amputation", and "TEG and amputation" was performed in Cochrane and PubMed databases to identify all peer-reviewed studies of TEG utilization in vascular surgery, written between 2000-2021 in the English language. The free text and MeSH subheadings search terms included diagnosis, complications, physiopathology, surgery, mortality, and therapy to further restrict the articles. Studies were excluded if they were not in humans or pertaining to vascular or endovascular surgery. Additionally, case reports and studies with limited information regarding TEG utilization were excluded. Each study was independently reviewed by two researchers to assess for eligibility. RESULTS Of the 262 studies identified through the MeSH strategy, 15 studies met inclusion criteria and were reviewed and summarized. Literature on TEG utilization in vascular surgery spanned cerebrovascular disease (n=3), peripheral arterial disease (n=3), arteriovenous malformations (n=1), venous thromboembolic events (n=7), and perioperative bleeding and transfusion (n=1). In cerebrovascular disease, TEG may predict the presence and stability of carotid plaques, analyze platelet function before carotid stenting, and compare efficacy of antiplatelet therapy after stent deployment. In peripheral arterial disease, TEG has been used to predict disease severity and analyze the impact of contrast on coagulation parameters. In venous disease, TEG may predict hypercoagulability and thromboembolic events among various patient populations. Finally, TEG can be utilized in the postoperative setting to predict hemorrhage and transfusion requirements. CONCLUSIONS This systematic review provides an up-to-date summarization of TEG utilization in multiple facets of vascular and endovascular surgery.
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Affiliation(s)
- Young Kim
- Division of Vascular and Endovascular Surgery Harvard Medical School, Massachusetts General Hospital Boston, MA
| | - Shiv S Patel
- Division of Vascular and Endovascular Surgery Harvard Medical School, Massachusetts General Hospital Boston, MA
| | - Imani E McElroy
- Division of Vascular and Endovascular Surgery Harvard Medical School, Massachusetts General Hospital Boston, MA
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery Harvard Medical School, Massachusetts General Hospital Boston, MA
| | - Tiffany R Bellomo
- Division of Vascular and Endovascular Surgery Harvard Medical School, Massachusetts General Hospital Boston, MA
| | - Monica Majumdar
- Division of Vascular and Endovascular Surgery Harvard Medical School, Massachusetts General Hospital Boston, MA
| | - Srihari K Lella
- Division of Vascular and Endovascular Surgery Harvard Medical School, Massachusetts General Hospital Boston, MA
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery Harvard Medical School, Massachusetts General Hospital Boston, MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery Harvard Medical School, Massachusetts General Hospital Boston, MA.
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Blei F. Update December 2020. Lymphat Res Biol 2020. [DOI: 10.1089/lrb.2020.29096.fb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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