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Gąsecka A, Zawadka M, Burban A, Idzik A, Gelo A, Graczyńska A, Jama K, Filipiak KJ, Jakimowicz T. Pre-operative platelet reactivity is a strong, independent predictor of bleeding complications after branched endovascular thoracoabdominal aortic aneurysm repair. Platelets 2021; 33:577-585. [PMID: 34355639 DOI: 10.1080/09537104.2021.1961708] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Endovascular aortic repair (EVAR) an alternative to open surgical repair of thoracoabdominal aortic aneurysm (TAAA). The effect of EVAR on platelet reactivity is unknown. We prospectively determined the effect of branched EVAR (bEVAR) on platelet reactivity in patients with TAAA, and evaluated the predictive value of preoperative platelet reactivity for post-operative bleeding in 50 consecutive patients undergoing elective bEVAR (mean age 70.9 ± 5.7 years, 66% male). Blood samples were collected within 24 hours before bEVAR, after bEVAR and at hospital discharge. Platelet reactivity was assessed with impedance aggregometry using ASPI, ADP and TRAP tests. Platelet reactivity decreased within 24 hours after bEVAR compared to the measurement before bEVAR in all tests (p ≤ 0.04), with a further decrease in hospital discharge in the ADP test (p = .004). Twenty-three patients experienced post-operative bleeding complications (transfusion ≥2 red blood cell [RBC] units). Preoperative platelet reactivity below the cutoff value of 30 AUC units predicted post-operative bleeding with 78% sensitivity and 59% specificity (p = .045). In the multivariable analysis, platelet reactivity was the only independent predictor of postoperative bleeding (OR 6.507, 95% CI 1.227-34.506, p = .028). We conclude that platelet reactivity decreases following bEVAR of TAAA and is a strong and independent predictor for postoperative bleeding complications.
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Affiliation(s)
- Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland.,Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mateusz Zawadka
- 2nd Department of Anesthesia and Intensive Care, Medical University of Warsaw, Warsaw, Poland.,Department of Perioperative Medicine, Barts Heart Centre and St. Bartholomew's Hospital, London, UK
| | - Anna Burban
- 1 Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Aleksandra Idzik
- 1 Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Agata Gelo
- 2nd Department of Anesthesia and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Agata Graczyńska
- 2nd Department of Anesthesia and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Jama
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof J Filipiak
- 1 Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Jakimowicz
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
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Colomina MJ, Méndez E, Sabate A. Altered Fibrinolysis during and after Surgery. Semin Thromb Hemost 2021; 47:512-519. [PMID: 33878781 DOI: 10.1055/s-0041-1722971] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Major surgery induces hemostatic changes related to surgical stress, tissue destruction, and inflammatory reactions. These changes involve a shift of volume from extravascular space to intravascular and interstitial spaces, a "physiologic" hemodilution of coagulation proteins, and an increase of plasmatic fibrinogen concentration and platelets. Increases in fibrinogen and platelets together with a simultaneous dilution of pro- and anticoagulant factors and development of a hypofibrinolytic status result in a postoperative hypercoagulable state. This profile is accentuated in more extensive surgery, but the balance can shift toward hemorrhagic tendency in specific types of surgeries, for example, in prolonged cardiopulmonary bypass or in patients with comorbidities, especially liver diseases, sepsis, and hematological disorders. Also, acquired coagulopathy can develop in patients with trauma, during obstetric complications, and during major surgery as a result of excessive blood loss and subsequent consumption of coagulation factors as well as hemodilution. In addition, an increasing number of patients receive anticoagulants and antiplatelet drugs preoperatively that might influence the response to surgical hemostasis. This review focuses on those situations that may change normal hemostasis and coagulation during surgery, producing both hyperfibrinolysis and hypofibrinolysis, such as overcorrection with coagulation factors, bleeding and hyperfibrinolysis that may occur with extracorporeal circulation and high aortic-portal-vena cava clamps, and hyperfibrinolysis related to severe maintained hemodynamic disturbances. We also evaluate the role of tranexamic acid for prophylaxis and treatment in different surgical settings, and finally the value of point-of-care testing in the operating room is commented with regard to investigation of fibrinolysis.
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Affiliation(s)
- Maria J Colomina
- Department of Anaesthesia and Critical Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain.,Universidad de Barcelona, Barcelona, Spain
| | - Esther Méndez
- Department of Anaesthesia and Critical Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain
| | - Antoni Sabate
- Department of Anaesthesia and Critical Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain.,Universidad de Barcelona, Barcelona, Spain
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Polok K, Górka J, Fronczek J, Iwaniec T, Górka K, Szczeklik W. Perioperative cardiovascular complications rate and activity of coagulation and fibrinolysis among patients undergoing vascular surgery for peripheral artery disease and abdominal aortic aneurysm. Vascular 2020; 29:134-142. [PMID: 32600160 DOI: 10.1177/1708538120937127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To compare preoperative coagulation and fibrinolysis activity and incidence of perioperative complications between patients undergoing vascular procedures for peripheral artery disease and abdominal aortic aneurysm. METHODS This is a substudy of a prospective observational cohort study (VISION; NCT00512109) in which we recruited patients aged ≥45 years, undergoing surgery for peripheral artery disease and abdominal aortic aneurysm. Blood samples were obtained 24 h preoperatively to measure platelet count, concentrations of coagulation coagulation (fibrinogen, factor VIII, von Willebrand factor:Ristocetin cofactor, antithrombin III), fibrinolysis (dimer D, plasmin-antiplasmin complexes, tissue plasminogen activator) markers and level of soluble CD40 ligand. Incidence of myocardial infarction, stroke, and death (composite endpoint) was assessed in 30-day follow-up. RESULTS The study group included 131 patients at the mean age of 68.3 years among whom reason for surgery was peripheral artery disease in 77 patients (58.8%) and abdominal aortic aneurysm in 54 patients (41.2%). Peripheral artery disease group was characterized by higher platelet count (250.5 versus 209.5 (×103/µl), p = 0.001), concentrations of fibrinogen (5.4 versus 4.1 (g/l), p < 0.001), factor VIII (176.9 versus 141.9 (%), p < 0.001), von Willebrand factor:Ristocetin cofactor (188.9 versus 152.3 (%), p = 0.009), and soluble CD40 ligand (9016.0 versus 7936.6 (pg/ml), p = 0.005). The dimer D level was higher (808.0 versus 2590.5 (ng/ml), p < 0.001) in the abdominal aortic aneurysm group. Incidence of major cardiovascular events (death, myocardial infarction, stroke) within 30 days from surgery did not differ between the groups (39.0% versus 29.6%, p = 0.27). CONCLUSIONS The study suggests higher activation of coagulation and relatively lower fibrinolytic activity in peripheral artery disease group compared to patients undergoing surgery for abdominal aortic aneurysm without a significant difference in cardiovascular outcomes.
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Affiliation(s)
- Kamil Polok
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland.,Department of Pulmonology, II Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Jacek Górka
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Jakub Fronczek
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Teresa Iwaniec
- Department of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Karolina Górka
- Department of Pulmonology, II Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Wojciech Szczeklik
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
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Kapetanios DM, Karkos CD, Papazoglou KO. Changes in circulating markers of coagulation and fibrinolysis after EVAR. INT ANGIOL 2018; 37:444-450. [DOI: 10.23736/s0392-9590.18.04046-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kapetanios D, Karkos CD, Pliatsios I, Mitka M, Giagtzidis IT, Konstantinidis K, Papazoglou KO. Association Between Perioperative Fibrinogen Levels and the Midterm Outcome in Patients Undergoing Elective Endovascular Repair of Abdominal Aortic Aneurysms. Ann Vasc Surg 2018; 56:202-208. [PMID: 30500639 DOI: 10.1016/j.avsg.2018.09.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/02/2018] [Accepted: 09/07/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND We investigated the potential association between perioperative fibrinogen levels and outcome in patients undergoing elective endovascular abdominal aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs). METHODS Consecutive patients with an intact AAA undergoing elective EVAR with a specific bifurcated endograft (Endurant, Medtronic) were recruited between December 2012 and October 2016. Preoperative and 24-hr postoperative fibrinogen levels were recorded, and potential associations with outcome were tested. Primary outcome measures included endoleaks, lower limb ischemic complications, including endograft limb occlusion, and aneurysm-related reinterventions. RESULTS Ninety-four patients (91 male, mean age 71.8 ± 8.0 years) with an intact AAA were enrolled in the study. The technical success was 98% (2 failures: 1 type Ia endoleak on completion angiography, 1 lower limb ischemia immediately postoperatively requiring femoral endarterectomy). There was 1 death during the first 30 days due to myocardial infarction (1%). Another patient died 15 months after the procedure from cardiac causes. During the existing follow-up (mean 14.8 ± 14.3 months), 14 patients (15%) developed an endoleak (4, type Ia endoleak and 10, type II endoleak), 6 patients (6.3%) had lower limb ischemia/endograft limb occlusion, and 10 patients (10.6%) required reintervention. Compared with the preoperative values, no significant change occurred with regard to the fibrinogen levels 24 hr after procedure (mean preoperative fibrinogen 360 ± 101 mg/dl vs 24-hr postoperative fibrinogen 349 ± 105 mg/dl, P = 0.1). Neither preoperative nor 24-hr postoperative fibrinogen levels were significantly associated with the development of endoleaks, lower limb ischemia, or reinterventions. However, the difference in fibrinogen levels (baseline to 24 hr after procedure) was significantly higher in patients with endoleaks (median -65 mg/dl vs. 15 mg/dl, P = 0.04). CONCLUSIONS Perioperative fibrinogen levels may play a role in predicting midterm outcomes in patients undergoing elective EVAR and appears to be associated, directly or indirectly, with the development of endoleaks. Further studies are needed to investigate these findings and explore future therapeutic implications.
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Affiliation(s)
- Dimitrios Kapetanios
- Vascular Surgery Unit, 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece
| | - Christos D Karkos
- Vascular Surgery Unit, 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece.
| | - Ioannis Pliatsios
- Vascular Surgery Unit, 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece
| | - Maria Mitka
- Vascular Surgery Unit, 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece
| | - Ioakeim T Giagtzidis
- Vascular Surgery Unit, 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece
| | - Konstantinos Konstantinidis
- Vascular Surgery Unit, 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece
| | - Konstantinos O Papazoglou
- Vascular Surgery Unit, 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece
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Abstract
Compulsory registration needed
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Affiliation(s)
- R J Hinchliffe
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
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Piechota-Polanczyk A, Jozkowicz A, Nowak W, Eilenberg W, Neumayer C, Malinski T, Huk I, Brostjan C. The Abdominal Aortic Aneurysm and Intraluminal Thrombus: Current Concepts of Development and Treatment. Front Cardiovasc Med 2015; 2:19. [PMID: 26664891 PMCID: PMC4671358 DOI: 10.3389/fcvm.2015.00019] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 04/10/2015] [Indexed: 01/09/2023] Open
Abstract
The pathogenesis of the abdominal aortic aneurysm (AAA) shows several hallmarks of atherosclerotic and atherothrombotic disease, but comprises an additional, predominant feature of proteolysis resulting in the degradation and destabilization of the aortic wall. This review aims to summarize the current knowledge on AAA development, involving the accumulation of neutrophils in the intraluminal thrombus and their central role in creating an oxidative and proteolytic environment. Particular focus is placed on the controversial role of heme oxygenase 1/carbon monoxide and nitric oxide synthase/peroxynitrite, which may exert both protective and damaging effects in the development of the aneurysm. Treatment indications as well as surgical and pharmacological options for AAA therapy are discussed in light of recent reports.
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Affiliation(s)
- Aleksandra Piechota-Polanczyk
- Department of Surgery, Medical University of Vienna , Vienna , Austria ; Department of Biochemistry, Medical University of Lodz , Lodz , Poland
| | - Alicja Jozkowicz
- Department of Medical Biotechnology, Jagiellonian University , Krakow , Poland
| | - Witold Nowak
- Department of Medical Biotechnology, Jagiellonian University , Krakow , Poland
| | - Wolf Eilenberg
- Department of Surgery, Medical University of Vienna , Vienna , Austria
| | | | - Tadeusz Malinski
- Department of Chemistry and Biochemistry, Ohio University , Athens, OH , USA
| | - Ihor Huk
- Department of Surgery, Medical University of Vienna , Vienna , Austria
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Bailey MA, Aggarwal R, Bridge KI, Griffin KJ, Iqbal F, Phoenix F, Purdell-Lewis J, Thomas T, Johnson AB, Ariëns RAS, Scott DJA, Ajjan RA. Aspirin therapy is associated with less compact fibrin networks and enhanced fibrinolysis in patients with abdominal aortic aneurysm. J Thromb Haemost 2015; 13:795-801. [PMID: 25660763 DOI: 10.1111/jth.12872] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Thrombotic changes in fibrin networks contribute to increased cardiovascular risk in patients with abdominal aortic aneurysm (AAA). Given that aspirin modulates the fibrin network, we aimed to determine if aspirin therapy is associated with changes in ex-vivo fibrin clot characteristics in AAA patients and also conducted an exploratory analysis of 5-year mortality in these individuals. METHODS We recruited 145 male patients, divided into controls (aortic diameter < 3 cm, n = 49), AAA not taking aspirin (AAA-Asp, n = 50) and AAA on 75 mg day(-1) aspirin (AAA+Asp, n = 46), matched for aneurysm size. Characteristics of clots made from plasma and plasma-purified fibrinogen were investigated using turbidimetric analysis, permeation studies, and confocal and electron microscopy. Plasma fibrinogen, D-dimer and inflammatory marker levels were also measured. RESULTS Maximum absorbance (MA) of plasma clots from controls was lower than that of AAA patients not on aspirin (AAA-Asp) at 0.30 ± 0.01 and 0.38 ± 0.02 au, respectively (P = 0.002), whereas aspirin-treated subjects had MA similar to controls (0.31 ± 0.02 P = 0.9). Plasma clot lysis time displayed an identical pattern at 482 ± 15, 597 ± 24 and 517 ± 27 s for control, AAA-Asp and AAA+Asp (P = 0.001 and P = 0.8). The lysis time of clots made from purified fibrinogen of AAA-Asp was longer than that of AAA+Asp patients (756 ± 47 and 592 ± 52 s, respectively; P = 0.041). Permeation studies and confocal and electron microscopy showed increased clot density in AAA-Asp compared with the AAA+Asp group. Mortality in AAA-Asp and AAA+Asp was similar, despite increased cardiovascular risk in the latter group, and both exhibited higher mortality than controls. CONCLUSION Aspirin improves fibrin clot characteristics in patients with AAA, which may have important clinical implications.
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Affiliation(s)
- M A Bailey
- Division of Cardiovascular & Diabetes Research, School of Medicine, The Leeds Institute of Cardiovascular & Metabolic Medicine, The University of Leeds, Leeds, UK; The Leeds Vascular Institute, The Leeds General Infirmary, Leeds, UK
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Trellopoulos G, Georgiadis GS, Nikolopoulos ES, Kapoulas KC, Georgakarakos EI, Lazarides MK. Antiplatelet Treatment and Prothrombotic Diathesis Following Endovascular Abdominal Aortic Aneurysm Repair. Angiology 2013; 65:783-7. [DOI: 10.1177/0003319713505139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Prothrombotic diathesis expressed by elevated levels of coagulation-specific biomarkers has been reported in patients with abdominal aortic aneurysm (AAA) and after AAA endovascular repair (EVAR). This study investigates the effect of antiplatelet agents (APLs) on the prothrombotic diathesis in the post-EVAR period. Forty elective EVAR patients had thrombin–antithrombin complex, d-dimer, fibrinopeptide A, and high-sensitivity C-reactive protein measured before, at 24 hours, 1 month, and 6 months after EVAR. Patients receiving APLs postoperatively were compared with those not receiving APLs. All biomarkers were above the normal limits preoperatively and increased significantly 24 hours postoperatively followed by a drop at 1 and 6 months. No statistically significant changes were noted among patients receiving APLs in comparison with those not receiving APLs. The preoperative and postoperative prothrombotic diathesis of AAA following EVAR was confirmed in line with other reports. There was however no significant alteration of the examined biomarkers in patients receiving APLs.
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Affiliation(s)
- G. Trellopoulos
- Department of Vascular Surgery, Democritus University Hospital, Alexandroupolis, Greece
| | - G. S. Georgiadis
- Department of Vascular Surgery, Democritus University Hospital, Alexandroupolis, Greece
| | - E. S. Nikolopoulos
- Department of Vascular Surgery, Democritus University Hospital, Alexandroupolis, Greece
| | - K. C. Kapoulas
- Department of Vascular Surgery, Democritus University Hospital, Alexandroupolis, Greece
| | - E. I. Georgakarakos
- Department of Vascular Surgery, Democritus University Hospital, Alexandroupolis, Greece
| | - M. K. Lazarides
- Department of Vascular Surgery, Democritus University Hospital, Alexandroupolis, Greece
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