Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions

Priorities for Clinical Research in Pediatric Extracorporeal Membrane Oxygenation Anticoagulation From the Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference

OBJECTIVES

To identify and prioritize research questions for anticoagulation and hemostasis management of neonates and children supported with extracorporeal membrane oxygenation (ECMO) from the Pediatric ECMO Anticoagulation CollaborativE (PEACE) consensus.

DATA SOURCES

Systematic review was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021, followed by serial consensus conferences of international, interprofessional experts in the management of ECMO for critically ill neonates and children.

STUDY SELECTION

The management of ECMO anticoagulation for critically ill neonates and children.

DATA EXTRACTION

Within each of the eight subgroups, two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts.

DATA SYNTHESIS

Following the systematic review of MEDLINE, EMBASE, and Cochrane Library databases from January 1988 to May 2021, and the consensus process for clinical recommendations and consensus statements, PEACE panel experts constructed research priorities using the Child Health and Nutrition Research Initiative methodology. Twenty research topics were prioritized, falling within five domains (definitions and outcomes, therapeutics, anticoagulant monitoring, protocolized management, and impact of the ECMO circuit and its components on hemostasis).

CONCLUSIONS

We present the research priorities identified by the PEACE expert panel after a systematic review of existing evidence informing clinical care of neonates and children managed with ECMO. More research is required within the five identified domains to ultimately inform and improve the care of this vulnerable population.

Management of Extracorporeal Membrane Oxygenation Anticoagulation in the Perioperative Period: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference

OBJECTIVES

To derive systematic review-informed, modified Delphi consensus regarding the management of children on extracorporeal membrane oxygenation (ECMO) undergoing invasive procedures or interventions developed by the Pediatric Anticoagulation on ECMO CollaborativE (PEACE) Consensus Conference.

DATA SOURCES

A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021.

STUDY SELECTION

ECMO anticoagulation and hemostasis management in the perioperative period and during procedures.

DATA EXTRACTION

Two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. Seventeen references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form.

DATA SYNTHESIS

Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. Four good practice statements, 7 recommendations, and 18 consensus statements are presented.

CONCLUSIONS

Although agreement among experts was strong, important future research is required in this population for evidence-informed recommendations.

Executive Summary: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE (PEACE) Consensus Conference

OBJECTIVES

To present recommendations and consensus statements with supporting literature for the clinical management of neonates and children supported with extracorporeal membrane oxygenation (ECMO) from the Pediatric ECMO Anticoagulation CollaborativE (PEACE) consensus conference.

DATA SOURCES

Systematic review was performed using PubMed, Embase, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021, followed by serial meetings of international, interprofessional experts in the management ECMO for critically ill children.

STUDY SELECTION

The management of ECMO anticoagulation for critically ill children.

DATA EXTRACTION

Within each of eight subgroup, two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts.

DATA SYNTHESIS

A systematic review was conducted using MEDLINE, Embase, and Cochrane Library databases, from January 1988 to May 2021. Each panel developed evidence-based and, when evidence was insufficient, expert-based statements for the clinical management of anticoagulation for children supported with ECMO. These statements were reviewed and ratified by 48 PEACE experts. Consensus was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed 23 recommendations, 52 expert consensus statements, and 16 good practice statements covering the management of ECMO anticoagulation in three broad categories: general care and monitoring; perioperative care; and nonprocedural bleeding or thrombosis. Gaps in knowledge and research priorities were identified, along with three research focused good practice statements.

CONCLUSIONS

The 91 statements focused on clinical care will form the basis for standardization and future clinical trials.

[Ablation of liver tumors : From pre-interventional imaging to post-interventional assessment]

The aim of this article is to provide an overview on the most frequently applied image-guided, percutaneous, local ablative techniques for treatment of primary and secondary liver tumors. The technical procedures of microwave ablation (MWA) and radiofrequency ablation (RFA) are presented. The pre-interventional diagnostics, indications and feasibility are also discussed, taking the current national guidelines into consideration. Finally, treatment outcomes and recommendations on post-interventional imaging following local tumor ablation are presented.

Percutaneous Nephrostomy as a Procedure in the Treatment of Urinary Tract Obstruction - Experiences in the University Clinic of Urology in Skopje

INTRODUCTION

Obstructive uropathy encompasses various urinary tract obstructions, leading to changes in urine flow, kidney pressure, and impaired kidney function. Predicting renal recovery from obstructive uropathy, can be challenging and necessitates treatment, as in percutaneous nephrostomy (PNS) drainage. The choice of drainage method depends on patient-specific factors and local expertise. According to the data for the Republic of North Macedonia, in the register of the European Renal Association, in the last few years, there has been an increase in the percentage of patients with obstructive nephropathy from 7.6% to 8.9% who end up on a chronic hemodialysis program. Prompt relief from urinary tract obstruction is essential to preserve renal function and prevent complications. The aim of this study is to present our initial data analysis of recent experience in the use of nephrostomies as a method for temporary or long-term resolution of obstructive nephropathy, in terms of safety and success in preserving kidney function and reducing the number of patients on hemodialysis.

MATERIALS AND METHODS

This study analyzed the medical records of 24 patients with obstructive uropathy who underwent PNS placement. Data were collected for the type and degree of obstruction from the ultrasonographic examination. A pig tail nephrostomy was used, with a dilator, guided under ultrasound and controlled with contrast and fluoroscope. Obstructive nephropathy was defined as an elevation of the serum creatinine > 109 µmol/L, before the intervention. Glomerular filtration rate (GFR) was calculated according to the formula CKD epi in ml/min. Each placement of the PNS was considered as an individual procedure and the data of 38 placed nephrostomies were analyzed. We compared the laboratory analyses from the day before (D0) PNS placement and on the seventh day (D7) after PNS placement. The reduction of values for red blood cells (RBC) and hemoglobin (Hb) baseline values from D0 to D7 and the need for transfusion after the procedure were defined as a complication-bleeding. The increase in total counts of the white blood cells (WBC) and C-reactive protein (CRP) from the baseline values from D0 to D7 were defined as a complication-infection. Standard statistical methods were used for data processing.

RESULTS

Most patients, 17 (70%), had malignant disease as the cause of obstruction. Unilateral obstruction was more common, detected in 24 (63%) of procedures, with a high degree of hydronephrosis. Obstructive nephropathy, marked by elevated serum creatinine, was observed in 23 (60%) cases before PNS placement. Complications included bleeding and infection but did not result in any fatalities. When comparing the laboratory analysis before PNS placement (D0) and seven days later (D7), a statistically significant decrease in serum creatinine (225±161 vs. 162±145, p=0.005) and an increase in GFR (47±39 vs.59±34, p= 0.005) were observed.

CONCLUSION

Percutaneous nephrostomy is a safe and effective treatment option for urinary tract obstruction, especially in patients with malignancies. Continuous monitoring is essential to assess long-term complications and the longevity of PNS functionality. This procedure offers a significant benefit in preserving renal function and minimizing the need for hemodialysis in these patients.

Plasma transfusion in critically Ill patients with abnormal coagulation tests before invasive procedures: A propensity-adjusted cohort study

OBJECTIVE

To evaluate the association between plasma transfusion and bleeding complications in critically ill patients with an elevated international normalized ratios undergoing invasive procedures.

METHODS

A retrospective study was conducted to evaluate a consecutive sample of critically ill adult patients undergoing invasive procedures (N = 487) with an international normalized ratio ≥ 1.5 between January 1, 2019 and December 31, 2019. Among the followed patients, 125 were excluded due to incomplete case records and 362 were finally included in this investigation. The exposure was whether plasma had been transfused within 24 h before the invasive procedure. The primary outcome was the occurrence of postprocedural bleeding complications. Secondary outcomes included transfusion of red blood cells within 24 h of the invasive procedure, and additional patient-important outcomes such as mortality and length of stay. Tests were performed with univariate and propensity-matched analyses.

RESULTS

Of the 362 study participants, 99 (27.3 %) received a preprocedural plasma transfusion. In the propensity score-matched analysis, the rate of the occurrence of postprocedural bleeding complications between two groups was not statistically different (OR, 0.605[95 % CI, 0.341-1.071]; P = .085). The rate of postoperative red blood cell transfusion in the plasma transfusion group was higher than that in the non-plasma transfusion group (35.5 % vs 21.5 %; P < .05). No statistically significant difference in mortality was observed between the two groups (29.0 % vs 31.6 %; P = .101).

CONCLUSIONS

Prophylactic plasma transfusion failed to reduce postprocedural bleeding complications in ill critically patients with a coagulopathy. Meanwhile, it was associated with increased red blood cell transfusion after invasive procedures. Findings suggest that abnormal preprocedural international normalized ratios should be managed more conservatively.

How Are We Handling Fluoroscopy-Guided Lumbar Puncture Requests? A Nationwide Survey of Practice Trends

BACKGROUND AND PURPOSE

Referrals to perform fluoroscopy-guided lumbar punctures by neuroradiologists have increased. The purpose of our study was to determine the management of fluoroscopy-guided lumbar puncture referrals in different practice settings.

MATERIALS AND METHODS

We sent an online questionnaire to neuroradiologists and radiology trainees between May and June 2020 to survey their handling of fluoroscopy-guided lumbar puncture requests, preprocedural work-up, and the use of physician extenders/trainees to perform fluoroscopy-guided lumbar punctures, among other questions. Categories were compared using ORs.

RESULTS

Of the 123 US respondents, 81.3% were in combined academic and 18.7% in combined private practice groups. Regarding fluoroscopy-guided lumbar puncture referrals, 27.6% of respondents did not require a bedside lumbar puncture attempt before a fluoroscopy-guided lumbar puncture. Of private practice, 95.7%, and of academic respondents, 85.0%, were often asked to perform fluoroscopy-guided lumbar punctures by clinicians because of the clinician's lack of procedural competence. Of those, 74.8% stated that they always or sometimes agreed to the request. 41.5% of respondents stated that they would always comply with patients' requests for a fluoroscopy-guided lumbar puncture without a bedside lumbar puncture attempt, a 5.26 times higher likelihood (95% CI, 2.04-14.29) for private practice respondents. To perform fluoroscopy-guided lumbar punctures, 32.0% of academic respondents and 47.8% of private practice respondents use physician extenders. 75.0% of academic respondents reported that trainees perform >50% of their fluoroscopy-guided lumbar punctures.

CONCLUSIONS

This survey demonstrates that many academic and private practice neuroradiologists engage in practices that may promote an increase in fluoroscopy-guided lumbar puncture referrals including not requiring a non-image-guided lumbar puncture attempt, complying with clinicians' requests for a fluoroscopy-guided lumbar puncture due to lack of competence in performing lumbar punctures, and fulfilling patient requests for fluoroscopy-guided lumbar punctures.

EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis

The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.

Gastrostomy tubes: Fundamentals, periprocedural considerations, and best practices

Gastrostomy tube placement is a procedure that achieves enteral access for nutrition, decompression, and medication administration. Preprocedural evaluation and selection of patients is necessary to provide optimal benefit and reduce the risk of adverse events (AEs). Appropriate indications, contraindications, ethical considerations, and comorbidities of patients referred for gastrostomy placement should be weighed and balanced. Additionally, endoscopist should consider either a transoral or transabdominal approach is appropriate, and radiologic or surgical gastrostomy tube placement is needed. However, medical history, physical examination, and imaging prior to the procedure should be considered to tailor the appropriate approach and reduce the risk of AEs.

Clinical Usefulness of Transjugular Liver Biopsy in Patients With Hematological Diseases With Liver Dysfunction

Introduction

Transjugular liver biopsy (TJLB) is indicated for patients in whom percutaneous liver biopsy is contraindicated, such as those with hematological diseases complicated by liver dysfunction. However, the clinical utility of TJLB in this group of patients has not been thoroughly investigated. The objective of this study is to evaluate the clinical efficacy of TJLB in patients with hematological diseases complicated by liver dysfunction.

Methods

We analyzed the data of patients who developed liver disorders during treatment for hematological diseases at our hospital and required tissue diagnosis via TJLB. The clinical features of patients were analyzed.

Results

Twenty-seven patients (mean age, 60.07 years; 12 men, 15 women) requiring tissue diagnoses via TJLB after developing liver disorders while undergoing treatment for hematological diseases were enrolled. One patient with autoimmune hemolytic anemia was diagnosed with drug-induced liver injury; two patients with amyloidosis had nonalcoholic steatohepatitis; one patient with acute promyelocytic leukemia had a drug-induced liver injury; one patient with chronic myelomonocytic leukemia had liver infiltration caused by an underlying disease; three patients with idiopathic thrombocytopenic purpura had autoimmune hepatitis; four patients with malignant lymphoma had liver infiltration by the underlying disease, and one patient with multiple myeloma had liver disorder caused by disseminated intravascular coagulation. Moreover, one patient had hepatitis B reactivation, another had hepatitis E, and six patients had a drug-induced liver injury. The treatment regimen was altered in cases of liver infiltration caused by the underlying disease, and the drug was changed for patients with drug-induced liver injury.

Conclusion

The etiology of liver disorders in patients with hematological diseases varies widely. Therefore, histological diagnosis using TJLB is useful to determine an appropriate therapeutic strategy for underlying hematological diseases.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Percutaneous Image-Guided Biliary Procedures

Percutaneous biliary interventions are among the commonly performed nonvascular radiological interventions. Most common of these interventions is the percutaneous transhepatic biliary drainage for malignant biliary obstruction. Other biliary procedures performed include percutaneous cholecystostomy, biliary stenting, drainage for bile leaks, and various procedures like balloon dilatation, stenting, and large-bore catheter drainage for bilioenteric or post-transplant anastomotic strictures. Although these procedures are being performed for ages, no standard guidelines have been formulated. This article attempts at preparing guidelines for performing various percutaneous image-guided biliary procedures along with discussion on the published evidence in this field.

N-Butyl Cyanoacrylate Embolization in Management of Iatrogenic Renal Hemorrhages—Single-Center Study Evaluating Safety and Efficacy

Objectives: The aim of the study was to evaluate the efficacy of endovascular N-butyl cyanoacrylate (NBCA)/glue embolization alone in the management of iatrogenic renal injuries and its effect on renal function.

Methods: Thirty-one patients who presented with significant iatrogenic renal injuries over a time period ranging from June 2013 to June 2018 were evaluated. The clinical features, lab parameters, and imaging findings were recorded. The embolizing agent used was exclusively NBCA. The success rate was calculated along with the effect of glue embolization on kidney in the form of postembolization ischemia and change in the serum creatinine levels in immediate pre- and postembolization period. The time between the iatrogenic injury and angioembolization as well as the time from angioembolization to discharge was also calculated. Recurrence was evaluated at 1 and 6 months follow-up.

Results: NBCA embolization showed 100% technical and clinical success in our study and no recurrence was noted at follow-up. Glue was also able to achieve complete embolization in patients with coagulopathy (n = 14, 45.1%). Percentage area deficit of normal renal blush in the postembolization check angiogram varied from 4 to 15.7% with a mean deficit of 7.65%. No significant difference in the serum creatinine was noted in immediate postembolization period.

Conclusions: We conclude that glue is an effective embolizing agent for management of iatrogenic renal injuries even in coagulopathy patients with minimal area of parenchymal loss, no significant effect on renal functions, and no recurrence on 6 months follow-up.

Avatrombopag and lusutrombopag for thrombocytopenia in people with chronic liver disease needing an elective procedure: a systematic review and cost-effectiveness analysis

BACKGROUND

There have been no licensed treatment options in the UK for treating thrombocytopenia in people with chronic liver disease requiring surgery. Established management largely involves platelet transfusion prior to the procedure or as rescue therapy for bleeding due to the procedure.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of two thrombopoietin receptor agonists, avatrombopag (Doptelet^®; Dova Pharmaceuticals, Durham, NC, USA) and lusutrombopag (Mulpleta^®; Shionogi Inc., London, UK), in addition to established clinical management compared with established clinical management (no thrombopoietin receptor agonist) in the licensed populations.

DESIGN

Systematic review and cost-effectiveness analysis.

SETTING

Secondary care.

PARTICIPANTS

Severe thrombocytopenia (platelet count of < 50,000/µl) in people with chronic liver disease requiring surgery.

INTERVENTIONS

Lusutrombopag 3 mg and avatrombopag (60 mg if the baseline platelet count is < 40,000/µl and 40 mg if it is 40,000-< 50,000/µl).

MAIN OUTCOME MEASURES

Risk of platelet transfusion and rescue therapy or risk of rescue therapy only.

REVIEW METHODS

Systematic review including meta-analysis. English-language and non-English-language articles were obtained from several databases including MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials, all searched from inception to 29 May 2019.

ECONOMIC EVALUATION

Model-based cost-effectiveness analysis.

RESULTS

From a comprehensive search retrieving 11,305 records, six studies were included. Analysis showed that avatrombopag and lusutrombopag were superior to no thrombopoietin receptor agonist in avoiding both platelet transfusion and rescue therapy or rescue therapy only, and mostly with a statistically significant difference (i.e. 95% confidence intervals not overlapping the point of no difference). However, only avatrombopag seemed to be superior to no thrombopoietin receptor agonist in reducing the risk of rescue therapy, although far fewer patients in the lusutrombopag trials than in the avatrombopag trials received rescue therapy. When assessing the cost-effectiveness of lusutrombopag and avatrombopag, it was found that, despite the success of these in avoiding platelet transfusions prior to surgery, the additional long-term gain in quality-adjusted life-years was very small. No thrombopoietin receptor agonist was clearly cheaper than both lusutrombopag and avatrombopag, as the cost savings from avoiding platelet transfusions were more than offset by the drug cost. The probabilistic sensitivity analysis showed that, for all thresholds below £100,000, no thrombopoietin receptor agonist had 100% probability of being cost-effective.

LIMITATIONS

Some of the rescue therapy data for lusutrombopag were not available. There were inconsistencies in the avatrombopag data. From the cost-effectiveness point of view, there were several additional important gaps in the evidence required, including the lack of a price for avatrombopag.

CONCLUSIONS

Avatrombopag and lusutrombopag were superior to no thrombopoietin receptor agonist in avoiding both platelet transfusion and rescue therapy, but they were not cost-effective given the lack of benefit and increase in cost.

FUTURE WORK

A head-to-head trial is warranted.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019125311.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 51. See the NIHR Journals Library website for further project information.

Central catheter-associated deep vein thrombosis in cancer: clinical course, prophylaxis, treatment

The adequate handling of central venous catheters is a key element in the management of patients with cancer. Catheter-associated deep vein thrombosis is frequently observed in patients with malignant diseases; however, despite being a common complication among these patients, objective information concerning its epidemiology, clinical course, prophylaxis and treatment strategies is very limited. The reported incidence of catheter-related thrombosis (CRT) is highly variable, depending on symptomatic events, or if patients are screened for asymptomatic thrombosis. Several factors have been identified as potential predisposing factors for CRT, both technical and pathological aspects. The anticoagulant of choice is still unclear; while low-molecular-weight heparin is most commonly used, recent studies assessing the role of direct oral anticoagulants in the treatment of CRT show promise as an alternative, but the evidence remains insufficient and the decision must be made on a case-by-case basis.

CT-guided percutaneous drainage of abdominopelvic collections: a pictorial essay

CT-guided percutaneous drainage is a safe and effective procedure that allows minimally invasive treatment of abdominopelvic abscesses and fluid collections. This technique has become an alternative for surgery with lower morbility and mortality rates. In this pictorial essay, we aim at providing an overview of the technical approaches, the main clinical indications and complications of CT-guided percutaneous drainage, in order to provide a practical guide for interventional radiologists, with a review of the recent literature. The focus will be the CT-guidance, preferred when the interposition of viscera, vascular and skeletal structures, counteracts the ultrasound guidance.

The coagulopathy of liver disease: a shift in thinking

The coagulopathy of chronic liver disease causes derangement of the results of traditional laboratory tests. As such, there is an expectation that when undergoing invasive procedures patients with cirrhosis are at increased risk of bleeding. Standard practice is to optimise laboratory values with prophylactic transfusions of platelets, plasma and fibrinogen to reduce perceived bleeding risk. There has been a shift in thinking regarding coagulation in patients with chronic liver disease, whereby a rebalancing of haemostasis occurs with reduction in both procoagulants and anticoagulants. Guidelines for the preprocedural management of patients with chronic liver disease are inconsistent and may not account for this new paradigm. The risk of prophylactic transfusion should be measured against the risk of bleeding while considering the rebalancing of haemostasis. Future management may be guided by whole blood viscoelastic tests or use of thrombopoietin receptor agonists to optimise patients in these scenarios.

Asian Conference on Tumor Ablation Guidelines for Adrenal Tumor Ablation

Thermal ablation is a good alternative treatment in patients who are unable to undergo adrenalectomy. Even though the Asian Conference on Tumor Ablation (ACTA) has been held for many years, adrenal ablation guidelines have not been established. No guidelines for adrenal ablation are established in American and European countries, either. The aim of this review was to introduce the first version of ACTA guidelines for adrenal tumor ablation.

Safety of endoscopic gastrostomy tube placement compared with radiologic or surgical gastrostomy: nationwide inpatient assessment

BACKGROUND AND AIMS

A gastrostomy tube is often required for inpatients requiring long-term nutritional access. We compared the safety and outcomes of 3 techniques for performing a gastrostomy: percutaneous endoscopic gastrostomy (PEG), fluoroscopy-guided gastrostomy by an interventional radiologist (IR-gastrostomy), and open gastrostomy performed by a surgeon (surgical gastrostomy).

METHODS

Using the Nationwide Readmissions Database, we identified hospitalized patients who underwent a gastrostomy from 2016 to 2017. They were identified using the International Classification of Diseases, 10th Revision, Procedure Coding System. The selected patients were divided into 3 cohorts: PEG (0DH64UZ), IR-gastrostomy (0DH63UZ), and open surgical gastrostomy (0DH60UZ). Adjusted odds ratios for adverse events associated with each technique were calculated using multivariable logistic regression analysis.

RESULTS

Of the 184,068 patients meeting the selection criteria, the route of gastrostomy tube placement was as follows: PEG, 16,384 (53.7 ± 29.0 years); IR-gastrostomy, 154,007 (67.2 ± 17.5 years); and surgical gastrostomy, 13,677 (57.9 ± 24.3 years). Compared with PEG, the odds for colon perforation using IR-gastrostomy and surgical gastrostomy, respectively, were 1.90 (95% confidence interval [CI], 1.26-2.86; P = .002) and 6.65 (95% CI, 4.38-10.12; P < .001), for infection of the gastrostomy 1.28 (95% CI, 1.07-1.53; P = .006) and 1.61 (95% CI, 1.29-2.01; P < .001), for hemorrhage requiring blood transfusion 1.84 (95% CI, 1.26-2.68; P = .002) and 1.09 (95% CI, .64-1.86; P = .746), for nonelective 30-day readmission 1.07 (95% CI, 1.03-1.12; P = .0023) and 1.13 (95% CI, 1.06-1.2; P = .0002), and for inpatient mortality 1.09 (95% CI, 1.02-1.17; P = .0114) and 1.55 (95% CI, 1.42-1.69; P < .0001).

CONCLUSIONS

Placement of a gastrostomy tube (PEG) endoscopically is associated with a significantly lower risk of inpatient adverse events, mortality, and readmission rates compared with IR-gastrostomy and open surgical gastrostomy.

Development of an Institutional Periprocedural Management Guideline for Oral Anticoagulants

Patients on oral anticoagulation commonly undergo surgery or other invasive procedures. Periprocedural management of oral anticoagulants involves a careful balance of the thromboembolic risk and bleeding risk. To standardize clinical practice at our institution, we developed a guideline for periprocedural management for patients taking oral anticoagulants that incorporates published data and expert opinion. In this article, we present our clinical practice guideline as a decision support tool to aid clinicians in developing a consistent strategy for managing periprocedural anticoagulation and for safely bridging anticoagulation in patients who require it.

A History of Coagulopathy in Liver Disease: Legends and Myths

Watch an interview with the author.

A Randomized Control Trial of Thromboelastography-Guided Transfusion in Cirrhosis for High-Risk Invasive Liver-Related Procedures

BACKGROUND AND AIM

Hemostasis in cirrhosis is dynamic and balanced. Thromboelastography (TEG) assesses global coagulation status. We aimed to assess whether TEG-guided blood product transfusions result in lower blood product requirements in patients with cirrhosis undergoing invasive liver-related procedures as compared to the conventional standard of care (SOC).

METHODS

In this open-label, randomized controlled trial, cirrhosis patients with coagulopathy, undergoing invasive liver-related procedures, were randomized to either TEG-guided blood product transfusion or SOC. The primary outcome was difference in the amount of fresh frozen plasma (FFP) and platelet units transfused between the two groups. The secondary outcome was procedure-related bleeding complications within 5 days and any complications until 28 days.

RESULTS

From November 2017 till June 2019, 58 patients were recruited (29: TEG and 29: SOC). Most common procedures performed were percutaneous liver biopsy (n = 48), followed by transjugular intrahepatic portosystemic shunt (n = 2), percutaneous acetic acid injection (n = 2), and transarterial chemoembolization (n = 2). There were no differences in baseline demographics, hemostatic profile, and types of procedures between the two groups. Only nine patients in TEG group received transfusions compared to all patients in SOC (31% vs 100%; P < 0.001). In TEG group, six (20.7%) received FFP (P = 0.753 vs. SOC), two (6.9%) received platelets (P < 0.001 vs. SOC), and 1(3.4%) patient received both FFP and platelet (P ≥ 0.999 vs. SOC) transfusion. None of the patients in either group developed procedure-related bleeding complications until 5 days post-procedure. The complication rates at 28-day follow-up were similar between the groups.

CONCLUSION

TEG-guided blood product transfusion strategy reduces blood product transfusion without increased risk of bleeding in cirrhotic patients undergoing invasive liver-related procedures (CTRI/2017/12/010822).

High-intensity focused ultrasound ablation of muscle in an anticoagulated swine model

Introduction: Image-guided non-invasive high-intensity focused ultrasound (HIFU) has been gaining recognition in treating musculoskeletal tumors and desmoids. However, there is no consensus on the appropriate perioperative management for patients on ongoing anticoagulation who undergo HIFU ablation.Material and methods: Image-guided HIFU treatment was performed in swine on an ongoing oral anticoagulation protocol (N = 5) in two treatment sessions seven days apart. On day one, a total of twenty locations were ablated, and on day eight, ten more muscle ablations were performed, and the animals were euthanized. Imaging, clinical examination, and histopathology were performed to investigate treated tissue for bleeding.Results: Imaging, clinical examination, and histopathology revealed either no bleeding or, in some samples, only small scattered cavities (0.2-2 mm in diameter) filled with blood.Conclusion: Noninvasive HIFU ablation of muscle may not require a coagulation profile within normal limits.

Percutaneous Nephrostomy in the Neonatal Period: Indications, Complications, and Outcome-A Single Centre Experience

PURPOSE

The purpose of this study was to evaluate the indications, technique for percutaneous nephrostomy (PCN) insertion, the complications related to PCN, duration of PCN, and outcome following PCN removal regarding the kidney function.

MATERIAL AND METHODS

Medical charts of 31 neonates (22 boys and 9 girls, mean age 13.9 days) treated with 43 PCN were reviewed. Collected data included indications for PCN, PCN complications, duration of PCN, and outcome of these patients by analysing the kidney function.

RESULTS

The indications for PCN insertion were obstructive urinary tract dilation in 24 neonates (four with associated infection), and non-obstructive urinary tract dilation with urosepsis or pyonephrosis in seven cases. Primary technical success of PCN placement using Seldinger technique was 97.7%. The following complications were reported: self-limited post-procedural bleeding into the pelvicalyceal system in two, chronic microscopic haematuria in five, and clinically manifested urinary tract infection in five children. Four PCN were dislocated. Cellulitis was present at the skin entry of 5 PCN, urinary leak in 5 PCN, and mechanical damage of 5 PCN. Eight PCN had to be replaced. Mean duration of PCN was 5 months. Kidney insufficiency was detected in 5/29 children with the mean follow-up of 3.9 years.

CONCLUSIONS

PCN is a safe, effective transient solution in neonates with pyonephrosis or when surgery of obstructed urinary system has to be postponed. The rate of minor complications increased with PCN duration. If kidney insufficiency is present after PCN removal, it is related to the complexity of kidney anomalies.

Periprocedural Outcomes in Patients on Chronic Anticoagulation Undergoing Fistulograms

BACKGROUND

Management of antithrombotic therapy with warfarin in patients undergoing fistulograms and possible interventions is controversial and difficult because of lack of adequate outpatient bridging options. Our goal was to assess periprocedural outcomes in patients managed using different anticoagulation strategies.

METHODS

A retrospective, single-institution analysis of all patients on chronic anticoagulation with warfarin undergoing fistulograms from 2011 to 2017 was performed. Anticoagulation management strategies were classified as suspended warfarin (SW), continued warfarin (CW), and a heparin bridge with suspended warfarin (HB). Periprocedural outcomes were analyzed.

RESULTS

There were 87 patients on chronic anticoagulation with warfarin who underwent 175 fistulograms. Median age was 63 years, and 43.4% were women. Indications for warfarin included atrial fibrillation (53%), prior pulmonary embolism/deep vein thrombosis (29%), and hypercoagulable state (14%). Distribution was SW (60%), CW (26%), and HB (14%). Approximately half (53%) were same-day procedures, 30% occurred during access-related admissions, and 14% were performed during nonaccess-related admissions. Common indications for a fistulogram included difficulty with dialysis (63.4%), access thrombosis (20.6%), and poor maturation (10.3%). Interventions included angioplasty (82.9%), thrombectomy/embolectomy (20.6%), and stenting (8.6%). Thirty-day outcomes for SW versus CW versus HB were similar for bleeding complications (5.7%, 6.5%, 8.3%; P = 0.89), systemic thrombotic complications (3.8%, 2.2%, 0%; P = 0.569), access rethrombosis (7.6%, 13%, 12.5%; P = 0.517), and tunneled dialysis catheter placement (11.4%, 13%, 12.5%; P = 0.958). After excluding procedures performed during a nonaccess-related admission, length of stay (LOS) was highest among HB (9.6 ± 7.8 days) compared with SW (2.6 ± 5.9 days) and CW (1 ± 2.8 days), (P < 0.0001).

CONCLUSIONS

CW therapy in patients undergoing fistulograms was not associated with increased morbidity and was associated with shorter LOS. Bridging with heparin is not associated with improved outcomes, warranting a thorough consideration of continuing warfarin is safe and may streamline preservation of dialysis accesses without significantly increasing resource utilization.

Percutaneous sclerotherapy with gelified ethanol of low-flow vascular malformations of the head and neck region: preliminary results

PURPOSE

We aimed to evaluate the safety and effectiveness of percutaneous sclerotherapy using gelified ethanol in patients with low-flow malformations (LFMs).

METHODS

A retrospective study was performed, analyzing treatment and outcome data of 6 patients that presented with 7 LFMs (3 lymphatic and 3 venous). Median diameter of LFMs was 6 cm (interquartile range [IQR], 4.5-8.5 cm). Data regarding pain, functional and/or cosmetic issues were assessed. Diagnosis was performed clinically and confirmed by Doppler ultrasound, while extension of disease was assessed by magnetic resonance imaging (MRI). Percutaneous puncture was performed with 23G needle directly or with ultrasound guidance. All the LFMs were treated with gelified ethanol injection. The median volume injected per treatment session was 4.4 mL.

RESULTS

Technical and clinical success were obtained in all cases. No recurrences were recorded during a median follow up of 17 months (IQR, 12-19 months). Among the 6 patients, 5 had complete relief (83%) and one showed improvement of symptoms. The median VAS score was 7 (IQR, 6-7.5) before and 0 (IQR, 0-0) after treatment. All patients had functional and esthetic improvement (100%). Four patients (66.7%) revealed very good acceptance and two patients (33.3%) good acceptance. No major complications or systemic side effects were observed.

CONCLUSION

Gelified ethanol percutaneous sclerotherapy was easy to handle, well-tolerated, safe and effective in the short-term follow-up. Longer follow-up of efficacy is mandatory for further conclusions.

Percutaneous microwave ablation therapy of renal cancer local relapse after radical nephrectomy: a feasibility and efficacy study

Renal cell carcinoma (RCC) local recurrence after radical nephrectomy is uncommon. When feasible, surgical removal remains the primary treatment strategy; nevertheless, local RCC relapse management is controversial, and less invasive procedures may represent an attractive option to achieve oncologic control. The aim of our study was to assess the feasibility, safety, and clinical outcomes of image-guided percutaneous microwave ablation (MWA) for RCC local recurrence in patients initially treated with nephrectomy with curative intent. 10 consecutive patients underwent CT-guided percutaneous MWA of a total of 10 retroperitoneal nodules. Inclusion criteria were: histologically verified retroperitoneal metastases, previous radical nephrectomy, lesion no larger than 3 cm, no other metastatic site elsewhere. All the procedures were performed under moderate sedation choosing the most favorable patient decubitus. If deemed necessary, pneumodissection was induced before ablation. After the antenna placement inside the target lesion, thermal ablation was achieved by maintenance of a power of 100 W for a total time between 2 and 4 min. All patients were observed overnight and discharged the following day if clinically stable. Technical success was obtained in 100% of patients. One patient was re-treated to complete oncologic response with repeat MWA. No major complications were observed. No patients demonstrated local recurrence at a mean follow-up of 26 months. MWA is a safe and effective treatment strategy for loco-regional relapse of RCC following radical nephrectomy. This technique may represent a valuable approach for patients who are not eligible for surgery.

Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding

Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.

Fresh frozen plasma transfusion in patients with cirrhosis and coagulopathy: Effect on conventional coagulation tests and thrombomodulin-modified thrombin generation

BACKGROUND & AIMS

The efficacy of fresh frozen plasma (FFP) transfusion in enhancing thrombin generation in patients with cirrhosis and impaired conventional coagulation tests has not been sufficiently explored. Thus, we aimed to assess the effect of FFP transfusion on thrombin generation in these patients.

METHODS

Fifty-three consecutive patients receiving a standard dose of FFP to treat bleeding and/or before invasive procedures - if international normalized ratio (INR)/prothrombin time (PT) ratio were ≥1.5 - were prospectively enrolled. The primary endpoint was the amelioration of endogenous thrombin potential (ETP) with thrombomodulin (ETP-TM) after transfusion, which corresponds to the total amount of generated thrombin. INR/PT ratio and activated partial thromboplastin time (aPTT) were also assessed before and after transfusion.

RESULTS

FFP enhanced ETP-TM by 5.7%, from 973 (731-1,258) to 1,028 (885-1,343 nM × min; p = 0.019). Before transfusion, evidence of normal or high ETP-TM was found in 94% of patients, even in those with bacterial infections. Only 1 (1.9%) patient had ETP-TM values reverting to the normal range after transfusion. Notably, no patients with low ETP-TM had bleeding. The median decrease in ETP-TM was 8.3% and the mean was 12.8% in 18 (34%) patients after transfusion (from 1,225 [1,071-1,537] to 1,124 [812-1,370] nM × min; p ≤0.0001). Similar responses to FFP transfusion were observed in patients with compensated and acute decompensated cirrhosis, acute-on-chronic liver failure, infection or shock. FFP significantly ameliorated INR and aPTT values (p <0.0001), but in a minority of patients the values were reduced to less than the cut-off point of 1.5.

CONCLUSIONS

FFP transfusion enhanced thrombin generation and ameliorated conventional coagulation tests to normal values in a limited number of patients, and slightly decreased thrombin generation in 34% of cases.

LAY SUMMARY

Transfusion of fresh frozen plasma in patients with cirrhosis only slightly improves coagulation test values in a limited number of patients and even appears to worsen them in a third of cases. Transfusion for the purpose of preventing or treating bleeding events could cause inherent risks and costs without clear benefits.

Two-Center Prospective Comparison of the Trocar and Seldinger Techniques for Percutaneous Cholecystostomy

OBJECTIVE. The purpose of this study is to compare the safety and efficacy of the bedside ultrasound (US)-guided trocar technique versus the US- and fluoroscopy-guided Seldinger technique for percutaneous cholecystostomy (PC). SUBJECTS AND METHODS. This prospective noninferiority study compared the bedside US-guided trocar technique for PC (the trocar group; 53 patients [28 men and 25 women]; mean [± SD] age, 74.31 ± 16.19 years) with the US- and fluoroscopy-guided Seldinger technique for PC (the Seldinger group; 52 patients [26 men and 26 women], mean age, 79.92 ± 13.38 years) in consecutive patients undergoing PC at two large tertiary university hospitals. The primary endpoints were technical success and procedure-related complication rates. Secondary endpoints included procedural duration, pain assessment, and clinical success after up to 3 months of follow-up. RESULTS. PC was successfully performed for all 105 patients. The clinical success rate was similar between the two study groups (86.8% in the trocar group vs 76.9% in the Seldinger group; p = 0.09). Mean procedural time was significantly lower in the trocar group than in the Seldinger group (1.77 ± 1.62 vs 4.88 ± 2.68 min; p < 0.0001). Significantly more procedure-related complications were noted in the Seldinger group than in the trocar group (11.5% vs 1.9%; p = 0.02). Among patients in the Seldinger group, bile leak occurred in 7.7%, abscess formation in 1.9%, and gallbladder rupture in 1.9%. No procedure-related death was noted. Minor bleeding occurred in one patient (1.9%) in the trocar group, but the bleeding resolved on its own. The mean pain score during the procedure was significantly lower in the Seldinger group than in the trocar group (3.2 ± 1.77 vs 4.76 ± 2.17; p = 0.01). At 12 hours after the procedure, the mean pain score was significantly lower for patients in the trocar group (0.78 ± 1.0 vs 3.12 ± 1.36; p = 0.0001). CONCLUSION. Use of the bedside US-guided trocar technique for PC was equally effective as the Seldinger technique but was associated with fewer procedure-related complications, required less procedural time, and resulted in decreased postprocedural pain, compared with fluoroscopically guided PC using the Seldinger technique.

Safety and efficacy of percutaneous microwave ablation for post-procedural haemostasis: a bi-central retrospective study focusing on safety and efficacy

OBJECTIVE

To review safety and efficacy of percutaneous microwave ablation (MWA) for post-procedural haemostasis.

METHODS

Institutional databases retrospective research identified 10 cases of iatrogenic bleeding who underwent percutaneous MWA for post-procedural haemostasis. Ultrasound examination with Doppler and contrast enhancement identified a source of active bleeding prior to ablation; additionally they were used as guiding modality for antenna insertion whilst, post-ablation, assessed the lack of active extravasation. Target locations included liver intercostal space spleen and thyroid gland. Technical success was defined as positioning of the antenna on the desired location. Treatment end point was considered the disappearance of active extravasation in both Doppler imaging and contrast-enhanced ultrasound.

RESULTS

Technical success (i.e. positioning of the antenna on the desired location) was achieved in all cases. No complications were noted. All patients post MWA remained haemodynamically stable with no need for transfusion and were discharged from the hospital the next morning. Imaging and clinical follow-up in all patients before exiting the hospital did not depict any sign of active extravasation or bleeding.

CONCLUSION

Our limited experience reports preliminary data showing that MWA could be added in the armamentarium of percutaneous therapies for iatrogenic bleeding. More prospective studies with larger patient samples are necessary for verification of this technique as well as for drawing broader conclusions in order to evaluate the place of percutaneous ablation in the treatment algorithm of haemorrhage.

ADVANCES IN KNOWLEDGE

Percutaneous ablation might have a role in haemostasis in well-selected cases.

Periprocedural Major Bleeding Risk of Image-Guided Percutaneous Chest Tube Placement in Patients with an Elevated International Normalized Ratio

PURPOSE

To evaluate the incidence of major hemorrhage after image-guided percutaneous chest tube placement in patients with an abnormal international normalized ratio (INR) measured before the procedure.

MATERIALS AND METHODS

Between January 2013 and September 2017, 49 image-guided percutaneous chest tubes were placed in 45 adult patients who had an elevated INR of greater than 1.6. Data collected included routine serum pre-procedure coagulation studies, indication for chest tube placement, insertion technique, size of chest tube, and presence of complications after drain placement. Major bleeding complications were defined using the Society of Interventional Radiology classification system.

RESULTS

Mean patient age was 62 years (range, 22-94 years), with median American Society of Anesthesiologists score of 4. Mean INR was 2.1 (range, 1.7-3), with 21 (43%) procedures with an INR between 1.7 and 1.9, 20 (41%) procedures with an INR between 2.0 and 2.4, and 8 (16%) procedures with an INR between 2.5 and 3.0. Computed tomography guidance was used for 27 (55%) procedures; ultrasound guidance was used for 22 (45%) procedures. Median size of chest tube was 10 Fr (range, 8-14 Fr) used in 27 (55%) procedures. No major bleeding complications were observed. There was a small, significant decrease in mean hemoglobin after the procedure (mean = 0.9g/dL; P < .0001), which correlated to increasing chest tube size (P = .0269).

CONCLUSIONS

No major bleeding complications were observed after image-guided percutaneous chest tube placement in patients with an elevated INR. Major bleeding complications in these patients may be safer than initially considered, and this study encourages the conduct of larger trials for further evaluation.

Diagnostic and therapeutic approach in adult patients with traumatic brain injury receiving oral anticoagulant therapy: an Austrian interdisciplinary consensus statement

There is a high degree of uncertainty regarding optimum care of patients with potential or known intake of oral anticoagulants and traumatic brain injury (TBI). Anticoagulation therapy aggravates the risk of intracerebral hemorrhage but, on the other hand, patients take anticoagulants because of an underlying prothrombotic risk, and this could be increased following trauma. Treatment decisions must be taken with due consideration of both these risks. An interdisciplinary group of Austrian experts was convened to develop recommendations for best clinical practice. The aim was to provide pragmatic, clear, and easy-to-follow clinical guidance for coagulation management in adult patients with TBI and potential or known intake of platelet inhibitors, vitamin K antagonists, or non-vitamin K antagonist oral anticoagulants. Diagnosis, coagulation testing, and reversal of anticoagulation were considered as key steps upon presentation. Post-trauma management (prophylaxis for thromboembolism and resumption of long-term anticoagulation therapy) was also explored. The lack of robust evidence on which to base treatment recommendations highlights the need for randomized controlled trials in this setting.

Percutaneous gastric tube placement: Comparison of trans-abdominal and trans-oral approach in patients with chronic ascites

PURPOSE

The purpose of this study was to compare the trans-abdominal (TA) and trans-oral (TO) approaches for fluoroscopic-guided gastrostomy tube placement in patients with chronic ascites.

MATERIALS AND METHODS

A 10-year review of clinical imaging and medical records at a single institution identified 29 patients with chronic recurrent ascites who underwent gastrostomy (GT) or gastro-jejunostomy tube (GJT) placement. In 22 patients (18 women, 4 men) aged from 22 to 76 years of age (mean age, 57.7±13.1 years), a GT or GJT was placed with the TO approach, and in 7 (7 women) from 31 to 86 years of age (mean age, 63±16.8 years) with the TA approach.

RESULTS

Technical success was 100% in both groups with one (1/22; 5%) immediate complication in the TO group. Fluoroscopy time was significantly greater in the TO group (P=0.002). Leakage of ascites was significantly more frequent in the TA group (P=0.04). There was no significant difference in bleeding or inflammation (P=0.14 and P=0.43, respectively). The cumulative tract related complication rate was significantly greater in the TA group (P=0.03).

CONCLUSION

Fluoroscopy times and the overall incidence of tract-related complications, in particular leakage of ascites from the stoma, are more frequent in patients in chronic ascites who underwent TA gastrostomy tube placement compared to those who underwent TO placement.

The Misunderstood Coagulopathy of Liver Disease: A Review for the Acute Setting

The international normalized ratio (INR) represents a clinical tool to assess the effectiveness of vitamin-K antagonist therapy. However, it is often used in the acute setting to assess the degree of coagulopathy in patients with hepatic cirrhosis or acute liver failure. This often influences therapeutic decisions about invasive procedures or the need for potentially harmful and unnecessary transfusions of blood product. This may not represent a best-practice or evidence-based approach to patient care. The author performed a review of the literature related to the utility of INR in cirrhotic patients using several scientific search engines. Despite the commonly accepted dogma that an elevated INR in a cirrhotic patient corresponds with an increased hemorrhagic risk during the performance of invasive procedures, the literature does not support this belief. Furthermore, the need for blood-product transfusion prior to an invasive intervention is not supported by the literature, as this practice increases the risk of complications associated with a patient's hospital course. Many publications ranging from case studies to meta-analyses refute this evidence and provide examples of thrombotic events despite elevated INR values. Alternative methods, such as thromboelastogram, represent alternate means of assessing in vivo risk of hemorrhage in patients with acute or chronic liver disease in real-time in the acute setting.

Avatrombopag Before Procedures Reduces Need for Platelet Transfusion in Patients With Chronic Liver Disease and Thrombocytopenia

BACKGROUND & AIMS

Patients with thrombocytopenia and chronic liver disease (CLD) may require platelet transfusions before scheduled procedures to decrease risk of bleeding. We performed 2 randomized, placebo-controlled, phase 3 trials in patients with thrombocytopenia and CLD undergoing scheduled procedures to evaluate the safety and efficacy of avatrombopag in increasing platelet counts in this patient population.

METHODS

In the ADAPT-1 and ADAPT-2 studies, adults with thrombocytopenia and CLD (n = 231 and n = 204, respectively) were in 1 of 2 cohorts according to their baseline platelet count (below 40 × 10⁹/L or 40 to below 50 × 10⁹/L) and within each cohort were randomized (2:1) to receive 5 daily doses of avatrombopag (60 mg if baseline platelet count below 40 × 10⁹/L or 40 mg if 40 to below 50 × 10⁹/L) or placebo. ADAPT-1 was conducted at 75 study sites in 20 countries, from February 2014 through January 2017, and ADAPT-2 was conducted at 74 sites in 16 countries, from December 2013 through January 2017. The primary endpoint was the proportion of patients not requiring platelet transfusions or rescue procedures for bleeding up to 7 days after a scheduled procedure.

RESULTS

In the ADAPT-1 study, 65.6% of patients who received 60 mg avatrombopag and 88.1% of patients who received 40 mg avatrombopag met the primary endpoint compared with 22.9% and 38.2% of patients receiving placebo, respectively (P < .0001 for both). In the ADAPT-2 study, 68.6% of patients who received 60 mg avatrombopag and 87.9% of patients who received 40 mg avatrombopag met the primary endpoint compared with 34.9% and 33.3% of patients who received placebo, respectively (P < .001 for both). Avatrombopag led to a measured increase in platelet counts and increased the proportion of patients who achieved the target platelet count ≥ 50 × 10⁹/L on procedure day vs placebo. The incidence and severity of adverse events were similar for the avatrombopag and placebo groups and were consistent with those expected in the CLD population.

CONCLUSIONS

In 2 phase 3 randomized trials, avatrombopag was superior to placebo in reducing the need for platelet transfusions or rescue procedures for bleeding in patients with thrombocytopenia and CLD undergoing a scheduled procedure. ClinicalTrials.gov nos.: NCT01972529 and NCT01976104.

Association of coagulopathy with the risk of bleeding after invasive procedures in liver cirrhosis

BACKGROUND/AIM

Bleeding risk among patients with acute or chronic liver disease after invasive procedures is a common concern in clinical practice. This retrospective study aimed to explore whether the presence of coagulopathy increased the risk of major bleeding after invasive procedures in cirrhosis.

PATIENTS AND METHODS

A total of 874 cirrhotic patients underwent invasive procedures. Coagulopathy was defined as international normalized ratio (INR) ≥1.5 and/or platelets (PLTs) ≤50 × 10⁹/L. Severe thrombocytopenia was defined as PLTs ≤ 50 × 10⁹/L. Invasive procedures, major bleeding after invasive procedures, and in-hospital deaths were recorded.

RESULTS

In all, 296 patients (33.9%) had coagulopathy. Major bleeding after invasive procedures occurred in 21 patients (2.4%). Major bleeding after invasive procedures was more frequent in patients with coagulopathy than those without coagulopathy (4.1% vs 1.6%, P = 0.023). Major bleeding after invasive procedures was more frequent in patients with severe thrombocytopenia than those without severe thrombocytopenia (4.9% vs 1.6%, P = 0.008). Incidence of major bleeding after invasive procedures was not significantly different between patients with INR ≥ 1.5 and INR < 1.5 (4.5% vs 2.0%, P = 0.065). Patients with INR ≥1.5 had a significantly higher in-hospital mortality than those with INR < 1.5 (6.4% vs 1.3%, P < 0.001).

CONCLUSION

Severe thrombocytopenia significantly increased the risk of major bleeding after invasive procedures in cirrhosis. INR ≥ 1.5 significantly increased in-hospital mortality.

Platelet-leucocyte aggregation is augmented in cirrhosis and further increased by platelet transfusion

BACKGROUND

Thrombocytopenia and circulating dysfunctional immune cells are commonly observed in patients with cirrhosis. Platelets may form complexes with neutrophils, monocytes and T cells modulating their function. We recently reported increased frequencies of platelet-complexed neutrophils in cirrhosis with evidence of neutrophil activation upon contact with healthy platelets in vitro. Whether this occurs in vivo following platelet transfusion and contributes to systemic inflammation and endothelial activation is unknown.

AIMS

To characterise platelet-leucocyte aggregation in cirrhosis and to determine whether elective platelet transfusion results in perturbations associated with changes in markers of haemostasis, inflammation or endothelial activation.

METHODS

We collected blood from cirrhotics (n = 19) before and following elective platelet transfusion. We measured platelet-leucocyte aggregation, activation and function, and markers of platelet activation, systemic inflammation and endothelial activation by flow cytometry. Haemostasis was assessed by thromboelastometry and plasma haemostatic proteins.

RESULTS

We observed a 2.5-fold increase in platelet-complexed neutrophils in patients with cirrhosis compared with healthy subjects and twofold more platelets attached per monocyte and T cell. All platelet-complexed leucocytes expressed higher levels of activation markers and platelet-complexed neutrophils had higher resting oxidative burst and phagocytic capacity than their nonplatelet-complexed counterparts (P < 0.001); most pronounced in patients with cirrhosis. Paradoxically, platelet-complexed leucocyte frequency decreased with increasing MELD score. Platelet transfusion increased soluble CD40 ligand (platelet activation marker), the frequency of platelet-complexed monocytes (P < 0.05) and improved haemostatic status.

CONCLUSION

Cirrhotic patients have activated circulating platelet-complexed leucocytes with increased platelet-monocyte aggregation following elective platelet transfusion. Elective platelet transfusion might therefore exacerbate immune dysfunction in cirrhosis.

Interventional radiology of the adrenal glands: current status

As more and more adrenal neoplasms are found incidentally or symptomatically, the need for interventional procedures has being increasing. In recent years these procedures registered continued steady expansion. Interventional radiology of the adrenal glands comprises angiographic and percutaneous procedures. They may be applied both in benign and in malignant pathologies. The present review reports the current status of indications, techniques results and complications of the image-guided procedures.

Safe Use of Low-Molecular-weight Heparin in Pediatric Acute Lymphoblastic Leukemia and Lymphoma Around Lumbar Punctures

Children with acute lymphoblastic leukemia or lymphoma (ALL) undergo multiple lumbar punctures (LPs) and frequently require low-molecular-weight heparin (LMWH) for thromboembolic complications. We evaluated if withholding LMWH 24 hours before and after LPs prevented bleeding complications. Children (n=133) with ALL from who were: (1) treated at St. Jude Children's Research Hospital, (2) received LMWH (2×/day of ~1 mg/kg) between January 2004 until December 2012, and (3) underwent a LP were analyzed. Spinal hematoma was defined as a clinical suspicion leading to diagnostic imaging. Traumatic LP was defined as ≥10 red blood cells per microliter of cerebrospinal fluid. In 1708 LPs, no hematomas occurred. For each child treated with LMWH, the probability of experiencing a spinal hematoma during the entire ALL treatment course was 0% (95% confidence interval [CI], 0.0%-2.7%), and in each LP, assuming no intrapatient correlation, the probability of spinal hematoma was 0% (95% CI, 0.0%-0.2%). Traumatic LPs were more common when performed when children were not receiving LMWH therapy (odds ratio [OR], 1.5; 95% CI, 1.1-2.2) which may be explained by clinician optimization of known risk factors for traumatic cerebrospinal fluid before the procedures. Withholding LMWH for 24 hours before and after LPs in children being treated for ALL is safe.

How do we reduce plasma transfusion in Rhode Island?

BACKGROUND

Plasma transfusions are given to patients with coagulopathy, either prophylactically, before an invasive procedure; or therapeutically, in the presence of active bleeding; and as an exchange fluid in therapeutic plasma exchange for disorders such as thrombotic thrombocytopenic purpura. There is consensus that many prophylactic plasma transfusions are non-efficacious, and the misdiagnosis of thrombotic thrombocytopenic purpura results in unnecessary therapeutic plasma exchange.

STUDY DESIGN AND METHODS

Beginning in 2001, programs to reduce plasma transfusion in the three major teaching hospitals in Rhode Island were initiated. The programs evolved through the establishment of guidelines, education for key prescribers of plasma, screening of plasma prescriptions, and engagement of individual prescribing physicians for out-of-guidelines prescriptions with modification or cancellation. Establishment of an in-house ADAMTS13 (ADAM metallopeptidase with thrombospondin type 1, motif 13) assay in 2013 was used to prevent therapeutic plasma exchange in patients with non-thrombotic thrombocytopenic purpura microangiopathy. Transfusion service data were gathered at the hospital level regarding blood component use, hospital data for discharges, inpatient mortality, and mean case-mix index, and, at the state level, for units of plasma shipped from the community blood center to in-state hospitals.

RESULTS

Between 2006 and 2016, a reduction in plasma use from 11,805 to 2677 units (a 77% decrease) was observed in the three hospitals and was mirrored in the state as a whole. This decline was not associated with any increase in red blood cell transfusion. Inpatient mortality either declined or was unchanged.

CONCLUSION

An active program focused on education and interdiction can achieve a large decrease in plasma transfusions without evidence of patient harm.