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Collie BL, Lyons NB, Goddard L, Cobler-Lichter MD, Delamater JM, Shagabayeva L, Lineen EB, Schulman CI, Proctor KG, Meizoso JP, Namias N, Ginzburg E. Optimal Timing for Initiation of Thromboprophylaxis After Hepatic Angioembolization. Ann Surg 2024; 280:676-682. [PMID: 38860373 DOI: 10.1097/sla.0000000000006381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
OBJECTIVE To evaluate the optimal timing of thromboprophylaxis (TPX) initiation after hepatic angioembolization in trauma patients. BACKGROUND TPX after hepatic trauma is complicated by the risk of bleeding, but the relative risk after hepatic angioembolization is unknown. METHODS Patients who underwent hepatic angioembolization within 24 hours were retrospectively identified from the 2017 to 2019 American College of Surgeons Trauma Quality Improvement Project data sets. Cases with <24-hour length of stay and other serious injuries were excluded. Venous thromboembolism (VTE) included deep venous thrombosis and PE. Bleeding complications included hepatic surgery, additional angioembolization, or blood transfusion after TPX initiation. Differences were tested with univariate and multivariate analyses. RESULTS Of 1550 patients, 1370 had initial angioembolization. Bleeding complications were higher in those with TPX initiation within 24 hours (20.0% vs 8.9%, P <0.001) and 48 hours (13.2% vs 8.4%, P =0.013). However, VTE was higher in those with TPX initiation after 48 hours (6.3% vs 3.3%, P =0.025). In the 180 patients with hepatic surgery before angioembolization, bleeding complications were higher in those with TPX initiation within 24 hours (72% vs 20%, P <0.001), 48 hours (50% vs 17%, P <0.001), and 72 hours (37% vs 14%, P =0.001). Moreover, deep venous thrombosis was higher in those with TPX initiation after 96 hours (14.3% vs 3.1%, P =0.023). CONCLUSIONS This is the first study to address the timing of TPX after hepatic angioembolization in a national sample of trauma patients. For these patients, initiation of TPX at 48 to 72 hours achieves the safest balance in minimizing bleeding while reducing the risk of VTE. LEVEL OF EVIDENCE Level III-retrospective cohort study.
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Affiliation(s)
- Brianna L Collie
- Dewitt Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL
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Lyons NB, O'Neil CF, Ramsey WA, Bhogadi S, Hosseinpour H, Collie BL, Ginzburg E, Proctor KG, Namias N, Joseph BA, Meizoso JP. Initial Hemorrhage Control Procedure for Splenic Injuries May Affect Risk of Venous Thromboembolism. J Surg Res 2024; 299:255-262. [PMID: 38781735 DOI: 10.1016/j.jss.2024.04.034] [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] [Received: 12/19/2023] [Revised: 04/17/2024] [Accepted: 04/24/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Venous thromboembolism (VTE) continues to be a major cause of morbidity in trauma. It is unclear whether the type of hemorrhage control procedure (i.e., splenectomy versus angioembolization) is associated with an increased risk of VTE. We hypothesize that hemodynamically stable patients undergoing angioembolization for blunt high-grade splenic injuries have lower rates of VTE compared to those undergoing splenectomy. METHODS The American College of Surgeons Trauma Quality Program dataset from 2017 to 2019 was queried to identify all patients with American Association for the Surgery of Trauma grade 3-5 blunt splenic injuries. Outcomes including VTE rates were compared between those who were managed with splenectomy versus angioembolization. Propensity score matching (1:1) was performed adjusting for age, sex, initial vital signs, Injury Severity Score, and splenic injury grade. RESULTS The analysis included 4698 matched patients (splenectomy [n = 2349] and angioembolization [n = 2349]). The median (interquartile range) age was 41 (27-58) years and 69% were male. Patients were well matched between groups. Angioembolization was associated with significantly lower VTE than splenectomy (2.2% versus 3.4%, P = 0.010) despite less use of VTE chemoprophylaxis (70% versus 80%, P < 0.001), as well as a relative delay in initiation of chemoprophylaxis (44 h versus 33 h, P < 0.001). Hospital and intensive care unit length of stay and mortality were also significantly lower in the angioembolization group. CONCLUSIONS Angioembolization is associated with a significantly lower incidence of VTE than splenectomy. Thus, angioembolization should be considered for initial management of hemodynamically stable patients with high-grade blunt splenic injuries in whom laparotomy is not otherwise indicated.
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Affiliation(s)
- Nicole B Lyons
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida.
| | - Christopher F O'Neil
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida
| | - Walter A Ramsey
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida
| | - Sai Bhogadi
- Department of Surgery, University of Arizona, Tucson, Arizona
| | | | - Brianna L Collie
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida
| | - Enrique Ginzburg
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida
| | - Kenneth G Proctor
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida
| | - Nicholas Namias
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida
| | - Bellal A Joseph
- Department of Surgery, University of Arizona, Tucson, Arizona
| | - Jonathan P Meizoso
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida
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Huang Z, Sun K, Luo Z, Zhang J, Zhou H, Yin H, Liang Z, You J. Spleen-targeted delivery systems and strategies for spleen-related diseases. J Control Release 2024; 370:773-797. [PMID: 38734313 DOI: 10.1016/j.jconrel.2024.05.007] [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] [Received: 02/13/2024] [Revised: 04/25/2024] [Accepted: 05/05/2024] [Indexed: 05/13/2024]
Abstract
The spleen, body's largest secondary lymphoid organ, is also a vital hematopoietic and immunological organ. It is regarded as one of the most significant organs in humans. As more researchers recognize the functions of the spleen, clinical methods for treating splenic diseases and spleen-targeted drug delivery systems to improve the efficacy of spleen-related therapies have gradually developed. Many modification strategies (size, charge, ligand, protein corona) and hitchhiking strategies (erythrocytes, neutrophils) of nanoparticles (NPs) have shown a significant increase in spleen targeting efficiency. However, most of the targeted drug therapy strategies for the spleen are to enhance or inhibit the immune function of the spleen to achieve therapeutic effects, and there are few studies on spleen-related diseases. In this review, we not only provide a detailed summary of the design rules for spleen-targeted drug delivery systems in recent years, but also introduce common spleen diseases (splenic tumors, splenic injuries, and splenomegaly) with the hopes of generating more ideas for future spleen research.
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Affiliation(s)
- Ziyao Huang
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China
| | - Kedong Sun
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China
| | - Zhenyu Luo
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China
| | - Junlei Zhang
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China
| | - Huanli Zhou
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China
| | - Hang Yin
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China
| | - Zhile Liang
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, 639 LongMian road, NanJing, JiangSu 211198, PR China
| | - Jian You
- College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou, Zhejiang 310058, PR China; Zhejiang-California International Nanosystems Institute, Zhejiang University, Hangzhou 310058, PR China; Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310058, Zhejiang, PR China.
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Collie BL, Lyons NB, O'Neil CF, Ramsey WA, Lineen EB, Schulman CI, Proctor KG, Meizoso JP, Namias N, Ginzburg E. When is it safe to start thromboprophylaxis after splenic angioembolization? Surgery 2024; 175:1418-1423. [PMID: 38418296 DOI: 10.1016/j.surg.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/12/2023] [Accepted: 01/02/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Thromboprophylaxis after blunt splenic trauma is complicated by the risk of bleeding, but the risk after angioembolization is unknown. We hypothesized that earlier thromboprophylaxis initiation was associated with increased bleeding complications without mitigating venous thromboembolism events. METHODS All blunt trauma patients who underwent splenic angioembolization within 24 hours of arrival were identified from the American College of Surgeons Trauma Quality Improvement Program datasets from 2017 to 2019. Cases with <24-hour length of stay, other serious injuries, and surgery before angioembolization were excluded. Venous thromboembolism was defined as deep vein thrombosis or pulmonary embolism. Bleeding complications were defined as splenic surgery, additional embolization, or blood transfusion after thromboprophylaxis initiation. Data were compared with χ2 analysis and multivariate logistic regression at P < .05. RESULTS In 1,102 patients, 84% had American Association for the Surgery of Trauma grade III to V splenic injuries, and 73% received thromboprophylaxis. Splenic surgery after angioembolization was more common in those with thromboprophylaxis initiation within the first 24 hours (5.7% vs 1.7%, P = .007), whereas those with the initiation of thromboprophylaxis after 72 hours were more likely to have a pulmonary embolism (2.3% vs 0.2%, P = .001). Overall, venous thromboembolism increased considerably when thromboprophylaxis was initiated after day 3. In multivariate analysis, time to thromboprophylaxis initiation was associated with bleeding (odds ratio 0.74 [95% confidence interval 0.58-0.94]) and venous thromboembolism complications (odds ratio 1.5 [95% confidence interval 1.20-1.81]). CONCLUSION This national study evaluates bleeding and thromboembolic risk to elucidate the specific timing of thromboprophylaxis after splenic angioembolization. Initiation of thromboprophylaxis between 24 and 72 hours achieves the safest balance in minimizing bleeding and venous thromboembolism risk, with 48 hours particularly serving as the ideal time for protocolized administration.
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Affiliation(s)
- Brianna L Collie
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL.
| | - Nicole B Lyons
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Christopher F O'Neil
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Walter A Ramsey
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Edward B Lineen
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Carl I Schulman
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Kenneth G Proctor
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Jonathan P Meizoso
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Nicholas Namias
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Enrique Ginzburg
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
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Timing and Type of Venous Thromboembolic Prophylaxis in Isolated Severe Liver Injury Managed Non-Operatively. World J Surg 2020; 45:746-753. [PMID: 33211165 DOI: 10.1007/s00268-020-05831-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The optimal timing and type of pharmacological venous thromboembolic prophylaxis (VTEp) after severe liver injury selected for nonoperative management (NOM) are controversial. The aim of this study was to assess the effect of timing and type of VTEp in severe liver injuries selected for NOM. METHODS ACS-TQIP database study (2013-17) including patients with blunt isolated severe liver injuries (AIS ≥ 3), selected for NOM, who received VTEp with either unfractionated heparin (UH) or low-molecular-weight heparin (LMWH). Patients who underwent laparotomy or angiointervention within 24 h or prior to the initiation of VTEp were excluded. The study population was stratified according to the timing of VTEp ≤ 48 h (EP) and > 48 h (LP) groups. Univariate and multivariate analyses were used to identify differences between the groups. RESULTS A total of 4074 patients was included in the study. 2004 (49.2%) received EP and 2070 (50.8%) LP. Patients with more severe injuries were more likely to receive LP than an EP [ISS 24 (19-29) vs 22 (17-27), p < 0.001]. On multivariate analysis (correcting for age, gender, comorbidities, blood pressure, GCS, ISS, type of VTEp), LP was identified as an independent risk factor for thromboembolic events (OR 1.52, p = 0.032) and mortality (OR 2.49, p = 0.031). LMWH was independently associated with lower mortality (OR 0.36, p = 0.007), compared to UH. EP did not increase the risk of laparotomy or angiointervention after starting VTEp, compared to LP (p = 0.992). CONCLUSION Early VTEp (≤ 48 h) is safe and independently associated with fewer thromboembolic events and a lower mortality after isolated severe liver injuries managed nonoperatively. LMWH was independently associated with improved outcomes when compared with UH.
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