scholarly journals Transhepatic tract hemostasis using thermal-ablation after percutaneous portal vein access

2021 ◽  
Author(s):  
Mathilde Vermersch ◽  
Alban Denys ◽  
Florent Artru ◽  
Georgia Tsoumakidou ◽  
Nicolas Villard ◽  
...  
Keyword(s):  
Portal Vein ◽  
Thermal Ablation ◽  
Bleeding Complication ◽  
Laboratory Data ◽  
Bleeding Risk ◽  
Hepatic Function ◽  
Advantages And Disadvantages ◽  
Vein Access ◽  
High Bleeding Risk

Objectives: Bleeding risk after percutaneous portal vein access procedures is not negligible. Various agents, coils and plug, have been used to minimize this risk, each with their own advantages and disadvantages. This study reports the results of coagulation using thermal-ablation (radiofrequency or microwave ablation) as an alternative to trans-hepatic puncture tract closure. Methods: Ten patients who benefited from portal vein recanalization or portal hypertension-relative bleeding complication embolization using percutaneous portal vein access and who underwent thermal-ablation of the puncture tract between December 30, 2019 and July 16, 2020 were included. Early efficiency and safety were evaluated using imaging (ultrasound and/or CT scan) and laboratory data (hemoglobin, hepatic function) at 24 h. Follow-up was performed until August 2020. Results: No bleeding from the puncture tract and no embolization-related complications were observed in all 10 patients at 24 h or during follow-up with median of 3 months (range 1–8 months), even in case of ascites or therapeutic coagulation. Conclusion: Thermal-ablation seems to be a safe, effective and rapid technique to avoid bleeding after percutaneous transhepatic direct portal vein access. Advances in knowledge: Thermal-ablation could be an alternative for transhepatic puncture tract closure especially for patients with high bleeding risk.

scholarly journals Bleeding Risk Profile in Patients on Oral Anticoagulation Undergoing Percutaneous Coronary Interventions: A Prospective 24 Months Cohort Study

2021 ◽  
Vol 8 ◽  
Author(s):  
Sara Schukraft ◽  
Tibor Huwyler ◽  
Cindy Ottiger-Mankaka ◽  
Sonja Lehmann ◽  
Ezia Cook ◽  
...  
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Primary Endpoint ◽  
Oral Anticoagulation ◽  
Academic Research ◽  
Bleeding Risk ◽  
Coronary Intervention ◽  
Risk Of Bleeding ◽  
Percutaneous Coronary ◽  
High Bleeding Risk

Background: The Academic Research Consortium has identified a set of major and minor risk factors in order to standardize the definition of a high bleeding risk (ACR-HBR). Oral anticoagulation is a major criterion frequently observed.Aims: The objective of this study is to quantify the risk of bleeding in patients on oral anticoagulation with at least one additional major ACR-HBR criteria in the Cardio-Fribourg Registry.Methods: Between 2015 and 2017, consecutive patients undergoing percutaneous coronary intervention were prospectively included in the Cardio-Fribourg registry. The study population included patients with ongoing long-term oral anticoagulation (OAC) and planned to receive triple antithrombotic therapy. Patients were divided in two groups: patients on OAC with at least one additional major ACR-HBR criteria vs. patients on OAC without additional major ACR-HBR criteria. The primary endpoint was any bleeding during the 24-month follow-up. Secondary bleeding endpoint was defined as Bleeding Academic Research Classification (BARC) ≥3.Results: Follow-up was completed in 142 patients at high bleeding risk on OAC, of which 33 (23%) had at least one additional major ACR-HBR criteria. The rate of the primary endpoint was 55% in patients on OAC with at least one additional ACR-HBR criteria compared with 14% in patients on OAC without additional ACR-HBR criteria (hazard ratio, 3.88; 95%CI, 1.85–8.14; p < 0.01). Patients with additional major ACR-HBR criteria also experienced significantly higher rates of BARC ≥ 3 bleedings (39% at 24 months).Conclusion: The presence of at least one additional ACR-HBR criterion identifies patients on OAC who are at very high risk of bleeding after percutaneous coronary intervention.

Ticagrelor versus Clopidogrel in high bleeding risk patients presenting with Acute Coronary Syndromes: insights from the multicenter START-ANTIPLATELET registry

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
F Gragnano ◽  
E Moscarella ◽  
P Calabro' ◽  
A Cesaro ◽  
P.C Pafundi ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndromes ◽  
Bleeding Risk ◽  
Coronary Intervention ◽  
P Value ◽  
Bleeding Events ◽  
P2y12 Inhibitors ◽  
Coronary Syndromes ◽  
High Bleeding Risk

Abstract Background Optimal dual antiplatelet therapy in high bleeding risk (HBR) patients with acute coronary syndromes (ACS) remains debated. Although current guidelines recommend the use of potent P2Y12 inhibitors in these patients (according to the labeled indications), clopidogrel is frequently used in clinical practice based on a perceived advantage in terms of safety in the HBR population. Purpose We sought to investigate the use of clopidogrel versus ticagrelor in consecutive HBR ACS patients and their impact on ischemic and bleeding events at 1 year. Methods ACS patients enrolled in the START-ANTIPLATELET registry with at least 1 HBR criterion were included in the present analysis and stratified according to DAPT type (clopidogrel versus ticagrelor). The primary endpoint was net adverse clinical endpoint (NACE), defined as a composite of all-cause death, myocardial infarction, stroke, and major bleeding. The secondary endpoints were major adverse cardiac and cerebral events (MACE), defined as a composite of all-cause death, myocardial infarction and stroke, each individual component of NACE and MACE, and target vessel revascularization. Results Among a total of 1,209 patients with 1-year follow-up in the registry, 383 patients were considered at HBR, of whom 174 (45.4%) were on clopidogrel and 209 (54.6%) on ticagrelor. Clopidogrel was more likely to be administered in patients at increased ischemic and bleeding risk, while ticagrelor in those undergoing percutaneous coronary intervention. Mean DAPT duration was longer in the ticagrelor group than in the clopidogrel group (10.40±4.29 versus 9.35±5.4; p-value=0.03). At 1-year follow-up, the risk of NACE and MACE events was significantly higher in the clopidogrel than in the ticagrelor group (NACE: HR 1.82; 95% CI 1.07–3.09; p-value=0.02; MACE: HR 1.83; 95% CI 1.04–3.24; p-value=0.03) (Figure). After multivariate adjustment for clinical and procedural characteristics, no difference in NACEs nor MACEs was observed between patients on clopidogrel versus ticagrelor (NACE: adjusted HR 1.27; 95% CI 0.71–2.27; p-value=0.42; MACE: adjusted HR 1.19; 95% CI 0.63–2.24; p-value=0.59) (Figure). Age, number of HBR criteria, and mean DAPT duration were independent predictors of NACEs. Conclusions In a real-world ACS registry, approximately 50% of patients are at HBR and frequently treated with clopidogrel. In HBR ACS patients, no difference was observed in ischemic and bleeding events between clopidogrel and ticagrelor after adjustment for potential confounders. Kaplan-Meier curves at 1-year follow-up. Funding Acknowledgement Type of funding source: None

P3726Percutaneous left atrial appendage closure and conservative antithrombotic treatment in patients with atrial fibrillation and contraindication to oral anticoagulation: a 5-year follow-up study

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J P Pouru ◽  
S Jaakkola ◽  
J Lund ◽  
F Biancari ◽  
A Saraste ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Major Bleeding ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Bleeding Risk ◽  
Left Atrial Appendage Closure ◽  
Bleeding Events ◽  
Device Embolization ◽  
High Bleeding Risk

Abstract Background Patients with atrial fibrillation (AF) having high thromboembolic risk and either a history of major bleeding or very high bleeding risk form a treatment challenge. Percutaneous left atrial appendage closure (LAAC) offers a feasible option for stroke prevention in these patients. However, the optimal treatment strategy for AF patients with contraindications to oral anticoagulation (OAC) remains unclear. Purpose To study periprocedural and late events after LAAC in AF patients with contraindications to OAC therapy. Methods Data were collected into a prospective registry from all consenting AF patients who underwent LAAC from February 2009 to August 2018. Follow-up data was gathered during scheduled clinical visits, annual phone calls and by reviewing electronic patient records. Only AF patients with contraindications to OAC were considered for the present analysis. Results LAAC using mainly Amplatzer Cardiac Plugs (98.2%) was attempted in a total of 172 patients (mean age 74 years; 60 women). The mean CHA2DS2-VASc score was 3.8±1.5 and HAS-BLED score 4.0±1.0. Contraindications to OAC were prior intracranial bleeding in 112 (65.1%), other major bleeding in 33 (19.2%) and high bleeding risk in 27 patients (15.7%). Procedure was technically successful in 166 (96.5%) patients. Clinically significant in-hospital complications were as follows: two patients (1.2%) had cardiac tamponade, which was fatal in one case, one (0.6%) had device embolization and eight (4.7%) had major access site-related bleeding events. None of the patients had in-hospital thromboembolic complications. After successful implantation, 152 patients (91.6%) were discharged on aspirin. Single antiplatelet therapy was more common than dual or triple antiplatelet therapy (74.7% vs. 18.1% vs. 1.8%, respectively), while 8 patients (4.8%) received no antiplatelet therapy. The length of initial antiplatelet therapy ranged from 0.5 to 12 months and long-term antiplatelet therapy was prescribed in 53 patients (31.9%). After a median follow-up of 33 months (interquartile range 12–49) there were 29 deaths (17.5%), 16 thromboembolic events (9.6%), consisting of 11 strokes (6.6%) and 5 transient ischemic attacks (3.0%). At the time of thromboembolic event, 10 patients (62.5%) were on antithrombotic therapy. Eighteen patients (10.8%) had at least one major bleeding event after the index hospitalization. Intracranial bleeding occurred in 7 patients (4.2%) and 6 of them (85.7%) were on antithrombotic therapy when the event occurred. Most thromboembolic events (68.8%) and intracranial bleedings (57.1%) occurred after one year of follow-up. One patient (0.6%) had an asymptomatic device embolization detected at 3-month control visit. No predictive factors for thromboembolic or major bleeding events were identified. Conclusion The early outcome of this challenging patient group is good after LAAC, but thromboembolic and major bleeding events are not uncommon during later follow-up.

Stand-Alone Thoracoscopic Left Atrial Appendage Closure in Nonvalvular Atrial Fibrillation Patients at High Bleeding Risk

2020 ◽  
Vol 15 (6) ◽  
pp. 541-546
Author(s):  
Marco Franciulli ◽  
Giuseppe De Martino ◽  
Mariateresa Librera ◽  
Ahmed Desoky ◽  
Antonio Mariniello ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Atrial Appendage ◽  
Nonvalvular Atrial Fibrillation ◽  
High Bleeding Risk ◽  
Laa Closure

Objective In nonvalvular atrial fibrillation (AF) patients at high bleeding risk, oral anticoagulants (OAC) may be contraindicated, and percutaneous left atrial appendage (LAA) closure has been advocated. However, following percutaneous procedure, either OAC or dual antiplatelet treatment is required. In this study, we present our experience in treating nonvalvular AF patients at high bleeding risk with thoracoscopic LAA closure with no subsequent antithrombotic therapy. Methods From April 2019 to January 2020, 20 consecutive AF patients, mean age 75.1 years, 16 (80%) males, underwent thoracoscopic LAA closure as a stand-alone procedure, using an epicardial clip device. OAC and antiplatelet therapy were contraindicated. Mean CHA2DS2-VASc score was 3.61, and the mean HAS-BLED score was 4.42. Successful LAA closure was assessed by transesophageal echocardiography. Primary endpoints were complete LAA closure (no residual LAA flow), operative complications, and all-cause mortality; secondary endpoints were 30-day and 6-month complications (death, ischemic stroke, hemorrhagic stroke, transient ischemic attack, any bleeding). Mean follow-up was 6 ± 4 months. Results Complete LAA closure was achieved in all patients. No operative clip-related complications or deaths occurred. At follow-up, freedom from postoperative complications was 95% and from any cerebrovascular events was 100%. Overall survival rate was 100%. Conclusions In nonvalvular AF patients at high bleeding risk (HAS-BLED score >3), thoracoscopic LAA closure appears to be a valid alternative to percutaneous techniques not requiring dual antiplatelet or OAC treatment. Apparently, external LAA clipping minimizes the risk of thromboembolic events as compared with percutaneous procedures.

scholarly journals Left Atrial Appendage Occlusion in High Bleeding Risk Patients

2019 ◽  
Vol 2019 ◽  
pp. 1-7 ◽  
Author(s):  
Pierluigi Merella ◽  
Giovanni Lorenzoni ◽  
Alessandro P. Delitala ◽  
Filomena Sechi ◽  
Federica Decandia ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Dual Antiplatelet Therapy ◽  
Bleeding Risk ◽  
Left Atrial Appendage Occlusion ◽  
Risk Patients ◽  
High Bleeding Risk

Objectives. The aim of this study was to investigate the outcomes of left atrial appendage occlusion (LAAO) in high bleeding risk patients suffering atrial fibrillation (AF) and to analyze the different antithrombotic therapies following the intervention. Background. Methods. This monocentric study included 68 patients with nonvalvular AF with an absolute contraindication to OAT or at high bleeding risk. Follow-up was done with a clinical visit at 3-6-12 months. Results. Successful LAAO was achieved in 67/68 patients. At discharge, 32/68 patients were on dual antiplatelet therapy (APT), 34/68 were without any antithrombotic therapy or with a single antiplatelet drug, and 2/68 were on anticoagulant therapy. At three-month follow-up visit, 73.6% of the patients did not receive dual APT, of whom 14.7% had no thrombotic therapy and 58.9% were on single antiplatelet therapy. During a follow-up of 1.4 ± 0.9 years, 3/62 patients had late adverse effects (2 device-related thrombus without clinical consequences and 1 extracranial bleeding). The device-related thrombosis was not related to the antithrombotic therapy. Conclusions. LAAO is feasible and safe and prevents stroke in patients with AF with contraindication to oral anticoagulant therapy. After LAAO, single antiplatelet therapy seems to be a safe alternative to dual antiplatelet therapy, especially in patients at high bleeding risk. No benefit has been observed with dual APT.

scholarly journals Tenecteplase in Pulmonary Embolism Patients: A Meta-Analysis and Systematic Review

2021 ◽  
Author(s):  
Zhu Zhang ◽  
Linfeng Xi ◽  
Shuai Zhang ◽  
Yunxia Zhang ◽  
Guohui Fan ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Meta Analysis ◽  
Random Effect ◽  
Random Effect Model ◽  
Bleeding Risk ◽  
Effect Model ◽  
High Bleeding Risk

Abstract OBJECTIVE: To assess the efficacy and safety of tenecteplase in patients with pulmonary embolism (PE). METHODS: We completed the literature search on May 31, 2021 using PubMed, EMBASE and the Web of Science. Analyses were conducted according to PE risk stratification, study design and duration of follow-up. The pooled risk ratios (RRs) and its 95% confident intervals (CIs) for death and major bleeding were calculated using a random-effect model.RESULTS: A total of six studies, with four randomized controlled trials (RCTs) and two cohort studies, were included in this study out of the 160 studies retrieved. For patients with high-risk PE, tenecteplase increased 30-day survival rate (16% vs 6%; P=0.005) and did not increase the incidence of bleeding (6% vs 5%; P=0.73). For patients with intermediate-risk PE, four RCTs suggested that tenecteplase reduced right ventricular insufficiency at 24h early in the onset and the incidence of hemodynamic failure without affecting mortality in a short/long-term [<30 days RR=0.83, 95% CI (0.47, 1.46);≥30 days RR=1.04, 95% CI (0.88, 1.22)]. However, tenecteplase was associated with high bleeding risk [<30 days RR=1.79, 95% CI (1.61, 2.00); ≥30 days RR=1.28, 95% CI (0.62, 2.64)].CONCLUSIONS: Tenecteplase may represent a promising candidate for patients with intermediate/high risk PE. Furthermore, tenecteplase may be preferable in the COVID-19 pandemic due to its all-at-once administration.

Cessation of oral anticoagulation is an important risk factor for stroke and mortality in atrial fibrillation patients

2017 ◽  
Vol 117 (07) ◽  
pp. 1448-1454 ◽  
Author(s):  
José Miguel Rivera-Caravaca ◽  
Vanessa Roldán ◽  
María Asunción Esteve-Pastor ◽  
Mariano Valdés ◽  
Vicente Vicente ◽  
...  
Keyword(s):  
Major Bleeding ◽  
Oral Anticoagulation ◽  
Cardiovascular Events ◽  
Bleeding Risk ◽  
The Elderly ◽  
Optimal Time ◽  
Bleeding Events ◽  
Artery Disease ◽  
High Bleeding Risk

SummaryOral anticoagulation (OAC) is highly effective preventing stroke and mortality in AF, but withdrawal is common in the elderly, when high bleeding risk and when are difficulties achieving an optimal time in therapeutic range (TTR). We analysed the rate of OAC cessation, predisposing factors to cessation and the relation to clinical outcomes in a large ‘real world’ cohort of AF patients over a long follow-up period. Consecutive non-valvular AF outpatients clinically stables for six months were recruited. Rates of cardiovascular events, major bleeding and mortality were recorded and related to OAC cessation. We included 1361 patients (48.7 % male; aged 76, IQR 71–81), followed-up for a median of 6.5 years. During follow-up, 244 patients suffered thrombotic events, 250 suffered from major bleeding and 551 patients died. 10 % of patients stopped OAC. After OAC withdrawal, there were 36 thromboembolic events (22 strokes), 10 major bleedings and 75 deaths. OAC cessation was independently associated with adverse cardiovascular events (HR 1.45; 95 % CI 1.01–2.08), stroke/TIA (HR 1.85; 1.17–2.94) and all-cause mortality (HR 1.30; 1.02–1.67). Independent predictors of OAC cessation were age ≥80 (HR 2.29; 1.60–3.29), previous coronary artery disease (HR 0.32; 0.15–0.71), major bleeding (HR 5.00; 3.49–7.15), heart failure (HR 2.38; 1.26–4.47), cancer (HR 5.24; 3.25–8.44) and renal impairment developed during follow-up (HR 2.70; 1.26–5.75). In conclusion, in non-valvular AF patients, cessation of OAC was independently associated with the risk of stroke, adverse cardiovascular events and mortality. Bleeding events and some variables associated with higher bleeding risk are responsible for OAC cessation.Note: The review process for this manuscript was fully handled by Christian Weber, Editor in Chief.Supplementary Material to this article is available online at www.thrombosis-online.com.

Abstract 79: Reasons for Warfarin Discontinuation in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF)

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Emily C O’Brien ◽  
DaJuanicia Holmes ◽  
Larry A Allen ◽  
Daniel E Singer ◽  
Gregg C Fonarow ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Warfarin Therapy ◽  
Atrial Fibrillation Patient ◽  
Anticoagulation Therapy ◽  
Bleeding Event ◽  
Bleeding Risk ◽  
Community Practice ◽  
One Year ◽  
High Bleeding Risk

Background. Warfarin reduces the risk of thromboembolic events associated with atrial fibrillation (AF), but therapeutic persistence is suboptimal. Few studies have investigated the reasons for warfarin discontinuation in community practice. Methods. We used data from ORBIT-AF, the nation’s largest AF database, to examine patterns of warfarin discontinuation over a one-year period. Patients transitioned to non-warfarin oral anticoagulation therapy were excluded. We compared patient and provider characteristics between individuals who discontinued warfarin and those who persisted. Results. From June 2010 to August 2011, 10,126 AF patients 18 years or older were enrolled at 176 ORBIT-AF practices. Of these, 6,559 (64.8%) were taking warfarin at baseline and have follow-up data; 514 (7.8%) of these switched to dabigatran and were excluded from the analysis. Additionally, two patients without follow-up warfarin data were excluded from the analysis. Over one year, 587 patients (9.7%) discontinued warfarin therapy. Compared to persistent users, patients who discontinued warfarin were younger, less likely to be white, had lower stroke risk (CHADS 2 <2), were more likely to follow a rhythm control strategy, and were less likely to be managed in an anticoagulation clinic (Table 1). The most commonly reported reasons for warfarin discontinuation were physician preference (31.0%), other (18.7%), patient refusal/preference (13.6%), bleeding event (13.3%), frequent falls/frailty (7.3%), high bleeding risk (6.6%), and patient inability to adhere to/monitor therapy (2.9%). Conclusions. Discontinuation of warfarin is common among patients with atrial fibrillation. Patient and physician preference are major contributors to persistence on warfarin therapy.

scholarly journals Ischemic and Bleeding Outcomes According to the Academic Research Consortium High Bleeding Risk Criteria in All Comers Treated by Percutaneous Coronary Interventions

2021 ◽  
Vol 8 ◽  
Author(s):  
Daphné Doomun ◽  
Ianis Doomun ◽  
Sara Schukraft ◽  
Diego Arroyo ◽  
Selma Cook ◽  
...  
Keyword(s):  
Risk Factors ◽  
Academic Research ◽  
Bleeding Risk ◽  
Coronary Intervention ◽  
Risk Of Bleeding ◽  
Increased Risk ◽  
Percutaneous Coronary ◽  
Research Consortium ◽  
High Bleeding Risk

Background: The Academic Research Consortium have identified a set of major and minor risk factors in order to standardize the definition of a High Bleeding Risk (ACR-HBR).Aims: The aim of this study is to stratify the bleeding risk in patients included in the Cardio-Fribourg registry, according to the Academic Research Consortium for High Bleeding Risk (ACR-HBR) definition, and to report ischemic and hemorrhagic events at 2-year of clinical follow-up.Methods: Between 2015 and 2017, consecutive patients undergoing percutaneous coronary intervention were prospectively included in the Cardio-Fribourg registry. Patients were considered high (HBR) or low (LBR) bleeding risk depending on the ARC-HBR definition. Primary endpoints were hierarchical major bleeding events as defined by the Bleeding Academic Research Consortium (BARC) grade 3–5, and ARC patient-oriented major adverse cardiac events (POCE) at 2-year follow-up.Results: Follow-up was complete in 1,080 patients. There were 354 patients in the HBR group (32.7%) and 726 patients in the low-bleeding risk (LBR) group (67.2%). At 2-year follow-up, cumulative BARC 3–5 bleedings were higher in HBR (10.5%) compared to LBR patients (1.5%, p &lt; 0.01) and the impact of HBR risk factors was incremental. At 2-year follow-up, POCE were more frequent in HBR (27.4%) compared to LBR group (18.2%, &lt;0.01). Overall mortality was higher in HBR (14.0%) vs. LBR (2.9%, p &lt; 0.01).Conclusions: ARC-HBR criteria appropriately identified a population at a higher risk of bleeding after percutaneous coronary intervention. An increased risk of bleeding is also associated with an increased risk of ischemic events at 2-year follow-up.

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