Endovascular Treatment for Lower-extremity Arterial Thrombosis in a Patient with Congenital Afibrinogenemia and a History of Bleeding Complications

Spider bites can cause local tissue damage as well as life-threatening complications. This is a case report of a female with no history of lower extremity vascular disease who presented with a spider bite on the dorsum of her foot. She developed progressive necrosis and eventually suffered limb loss despite attempts at revascularization.

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Anticoagulation in addition to dual antiplatelet therapy has no impact on long-term follow-up after endovascular treatment of (sub)acute lower limb ischemia

VASA ◽

10.1024/0301-1526/a000786 ◽

2019 ◽

Vol 48 (4) ◽

pp. 321-329

Author(s):

Mariya Kronlage ◽

Erwin Blessing ◽

Oliver J. Müller ◽

Britta Heilmeier ◽

Hugo A. Katus ◽

...

Keyword(s):

Endovascular Treatment ◽

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

Limb Ischemia ◽

Bleeding Complications ◽

Severe Bleeding ◽

Short Term ◽

Long Term Follow Up

Summary. Background: To assess the impact of short- vs. long-term anticoagulation in addition to standard dual antiplatelet therapy (DAPT) upon endovascular treatment of (sub)acute thrombembolic occlusions of the lower extremity. Patient and methods: Retrospective analysis was conducted on 202 patients with a thrombembolic occlusion of lower extremities, followed by crirical limb ischemia that received endovascular treatment including thrombolysis, mechanical thrombectomy, or a combination of both between 2006 and 2015 at a single center. Following antithrombotic regimes were compared: 1) dual antiplatelet therapy, DAPT for 4 weeks (aspirin 100 mg/d and clopidogrel 75 mg/d) upon intervention, followed by a lifelong single antiplatelet therapy; 2) DAPT plus short term anticoagulation for 4 weeks, followed by a lifelong single antiplatelet therapy; 3) DAPT plus long term anticoagulation for > 4 weeks, followed by a lifelong anticoagulation. Results: Endovascular treatment was associated with high immediate revascularization (> 98 %), as well as overall and amputation-free survival rates (> 85 %), independent from the chosen anticoagulation regime in a two-year follow up, p > 0.05. Anticoagulation in addition to standard antiplatelet therapy had no significant effect on patency or freedom from target lesion revascularization (TLR) 24 months upon index procedure for both thrombotic and embolic occlusions. Severe bleeding complications occurred more often in the long-term anticoagulation group (9.3 % vs. 5.6 % (short-term group) and 6.5 % (DAPT group), p > 0.05). Conclusions: Our observational study demonstrates that the choice of an antithrombotic regime had no impact on the long-term follow-up after endovascular treatment of acute thrombembolic limb ischemia whereas prolonged anticoagulation was associated with a nominal increase in severe bleeding complications.

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Abstract TP36: Predictors and Associated Outcomes of Subarachnoid Hemorrhage Following Endovascular Treatment for Acute Ischemic Stroke

Stroke ◽

10.1161/str.47.suppl_1.tp36 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Alexandros L Geordiadis ◽

Muhammad A Saleem ◽

Adnan I Qureshi

Keyword(s):

Heart Disease ◽

Subarachnoid Hemorrhage ◽

Ischemic Heart Disease ◽

Endovascular Treatment ◽

Univariate Analysis ◽

Prospective Trial ◽

Endovascular Intervention ◽

Ischemic Heart ◽

History Of ◽

Stroke Trial

Introduction: The rates of occurrence, predictors, and associated outcomes of subarachnoid hemorrhage (SAH) following endovascular treatment are not well studied. Methods: We retrospectively analyzed data from the Interventional Management of Stroke Trial (IMS III). This prospective trial randomized patients to intravenous (IV) rt-PA alone versus IV rt-PA followed by endovascular intervention. All patients underwent computed tomography (CT) at 24 hours post randomization. The scans were assessed by independent reviewers at a core laboratory for the presence, location, and type of intracranial hemorrhage.The primary outcome assessment was by modified Rankin Scale (mRS) score at 3 months. Results: Thirty four out of 434 (7.8%) patients who received endovascular treatment suffered SAH at 24 hours. There were 19 men (55.9%), and 19 patients were older than 70 years.In univariate analysis only pre-existing ischemic heart disease was identified as a predictor of SAH (p=0.03) while patient age was borderline significant (p=0.055). Three-monthmRS score was available for 24/34 patients with SAH and for 318/400 among the other patients. There was no difference in mortality (12.5% vs. 4.1%, p=0.167) or favorable outcome defined as mRS =<2 (41.7% vs. 53.5%, p=0.366). Conclusions: SAH following endovascular intervention for acute stroke is more common among patients with history of ischemic heart disease. It does not impact on functional outcome or mortality at 3 months.

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Abstract 2825: History of Cancer Predicts Mortality After Acute Endovascular Treatment for Ischemic Stroke

Stroke ◽

10.1161/str.43.suppl_1.a2825 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Karl Meisel ◽

Mahesh Jayaraman ◽

Jonathan Grossberg ◽

Anthony Kim

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Hospice Care ◽

Exploratory Analysis ◽

Endovascular Intervention ◽

Consecutive Series ◽

History Of ◽

History Of Cancer

Introduction: Endovascular treatment is an emerging therapy for acute ischemic stroke. There is no clear consensus about how best to select patients that may benefit from intervention. We conducted an exploratory analysis of clinical risk factors to predict mortality after endovascular intervention in order to better understand how to improve outcomes for patients with acute ischemic stroke. Methods: We identified consecutive series of patients treated with endovascular therapy for acute ischemic stroke at two academic hospitals between 2005 to 2010. Key clinical data elements and clinical outcomes at the time of discharge were abstracted from medical records. We evaluated univariate and multivariable associations using logistic regression and compared mean NIH Stroke Scale between those with and without a history of cancer using the t-test. Results: We identified 88 patients who received endovascular intervention with intra-arterial tissue plasminogen activator (t-PA) and/or mechanical thrombectomy. The mean age of the cohort was 68.2 (SD 16.6) and 44 (55%) were female. A total of 23 (26.1%) patients died during the index hospitalization or were discharged to hospice care. A history of cancer was documented in 20 (22.7%) patients. A history of cancer was associated with a 3.2-fold (95% CI 1.1-9.1) higher odds of mortality. This association persisted after adjusting for age greater than 80 years and hypertension (OR of 4.0, 95% CI 1.3-12). The average NIH Stroke Scale was 15.6 in those with cancer compared to 14.6 without (p=0.53). A history of cancer was not associated with parenchymal hemorrhagic transformation (OR 1.2, 95% CI 0.3-4.9), IV tPA (OR 0.5, 95% CI 0.1-2.3), a TIMI score of 2b or 3 (OR 0.5, 95% CI 0.2-1.3), or an internal carotid artery occlusion (OR 1.7, 95% CI 0.5-5.1). Conclusions: In an exploratory analysis of consecutive patients with acute ischemic stroke treated with endovascular therapy, a history of cancer was strongly associated with significantly increased odds of mortality. One possible explanation could be that patients with cancer may have earlier withdrawal of care but the reasons for this observed association are unclear. Further investigation is necessary to verify and explain the reasons for this observation in order to improve outcomes for acute ischemic stroke patients.

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Are hypertensive patients with history of coronary artery disease at risk for silent lower extremity artery disease?

Journal of Basic and Clinical Physiology and Pharmacology ◽

10.1515/jbcpp-2021-0235 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Eka Prasetya Budi Mulia ◽

Kevin Yuwono ◽

Raden Mohammad Budiarto

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Lower Extremity ◽

Pearson Correlation ◽

Ankle Brachial Index ◽

Chi Square ◽

Hypertensive Patients ◽

History Of ◽

Artery Disease ◽

Lower Extremity Artery Disease

Abstract Objectives We aimed to investigate the association between hypertension and asymptomatic lower extremity artery disease (LEAD) in outpatients with known history of coronary artery disease (CAD). Methods Patients with known history of CAD who have been undergone coronary angiography and have significant coronary artery stenosis (more than 60%) were included. LEAD was defined as ankle-brachial index (ABI) < 0.9 in either leg. The risk of LEAD in hypertensive group was analyzed using chi-square test, and correlation between blood pressure (BP) and ABI was analyzed using Pearson correlation test in SPSS v.25. Results One hundred and four patients were included. 82.7% of patients were male. Mean age was 57.05 ± 7.97. The prevalence of hypertension was 35.6%, and the prevalence of LEAD was 16.3%. A higher proportion of LEAD was found in hypertensive (18.9%) compared to non-hypertensive (14.9%), although not statistically significant (OR: 1.33; 95% CI: 0.46 to 3.85; p=0.598). There was an association between ABI and systolic BP (p=0.016), but not with diastolic BP (p=0.102). Conclusions Our study showed that the prevalence of LEAD in hypertension, especially in the CAD population, is relatively high. There was no association between hypertension and LEAD, but a higher prevalence of LEAD was found in hypertensive patients. Nevertheless, LEAD screening is still recommended in hypertensive patients, especially in the CAD population, given the fact that outcomes of health and mortality are worse for those with concomitants of these diseases.

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Correlation between Restless Leg Syndrome and Superficial Venous Reflux

International Journal of Angiology ◽

10.1055/s-0041-1730447 ◽

2021 ◽

Author(s):

Aaron R. Dezube ◽

Jake Rauh ◽

Michael Dezube ◽

Mark Iafrati ◽

JoAnn Rigo ◽

...

Keyword(s):

Logistic Regression ◽

Family History ◽

Lower Extremity ◽

Symptom Improvement ◽

Venous Disease ◽

Restless Leg Syndrome ◽

Venous Reflux ◽

Common Cause ◽

History Of ◽

Prospective Trials

AbstractRestless leg syndrome (RLS) is a common cause of lower extremity discomfort. We hypothesized that patients with RLS symptoms have higher rates of deep and superficial venous reflux (SVR). Retrospective review of patients ≥18 years of age evaluated in a venous center from December 2018 to February 2019. Differences in rates of RLS symptoms, demographics, comorbidities, and clinical and radiologic presence of venous disease were analyzed. Overall, 207 patients were analyzed; 140 (67.6%) reported RLS symptoms (n = 25 with prior RLS diagnosis). RLS symptoms were more common with superficial or combined superficial and deep venous reflux (DVR) compared with those without reflux (p < 0.001). Patients with RLS symptoms as opposed to those without had similar demographics and comorbidities (all p > 0.05) but increased rates of venous pain, phlebitis, family history of venous disease, lower extremity swelling and SVR, and combined SVR and DVR (all p < 0.05). Our multivariable logistic regression found presence of SVR, and family history of venous reflux was associated with RLS symptomatology (all p < 0.001). Ninety-nine patients with RLS underwent ablation; of them, 93 had duplex-proven reflux resolution of which 81 (87%) reported RLS symptom improvement. This included 13 of 16 (81.3%) with prior RLS diagnosis. SVR is associated with increased rates of RLS symptoms in a vein center population. Therefore, RLS symptoms should trigger a targeted venous evaluation. Our results suggest that venous ablation may lead to resolution of RLS symptoms in patients with SVR, but randomized prospective trials with strict RLS definition criteria are warranted to confirm these outcomes.

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Self-Myofascial Release of the Superficial Back Line Improves Sit-and-Reach Distance

Journal of Sport Rehabilitation ◽

10.1123/jsr.2018-0306 ◽

2020 ◽

Vol 29 (4) ◽

pp. 400-404 ◽

Cited By ~ 1

Author(s):

Whitney Williams ◽

Noelle M. Selkow

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Lower Extremity ◽

Low Back ◽

Myofascial Release ◽

Plantar Surface ◽

The Past ◽

Plantar Aspect ◽

History Of ◽

Hamstring Flexibility

Context: Decreased hamstring flexibility can lead to a plethora of musculoskeletal injuries, including low back pain, hamstring strains, and patellofemoral pain. Lack of flexibility may be the result of myofascial adhesions. The fascia connected to the hamstrings is part of the superficial back line that runs from the cranium to the plantar aspect of the foot. Any disruption along this chain may limit the flexibility of the hamstring. Objective: To investigate if self-myofascial release (SMR) of the plantar surface of the foot in addition to the hamstring group was more effective at improving the flexibility of the hamstrings when compared with either intervention alone. Design: Cross-over study. Setting: Athletic training facility. Participants: Fifteen college students (5 males and 10 females; age: 20.9 [1.4] y, height: 173.1 [10.3] cm, mass: 80.0 [24.9] kg) who were not older than 30, with no history of low back pain or injury within the past 6 months, no history of leg pain or injury within the past 6 months, no current signs or symptoms of cervical or lumbar radicular pain, no current complaint of numbness or tingling in the lower-extremity, and no history of surgery in the lower-extremity or legs. Interventions: Each participant received each intervention separated by at least 96 hours in a randomized order: hamstring foam rolling, lacrosse ball on the plantar surface of the foot, and a combination of both. Main Outcome Measures: The sit-and-reach test evaluated hamstring flexibility of each participant before and immediately after each intervention. Results: There were no significant differences found among the SMR techniques on sit-and-reach distance (F2,41 = 2.7, P = .08, ). However, at least 20% of participants in each intervention improved sit-and-reach distance by 2.5 cm. Conclusions: SMR may improve sit-and-reach distance, but one technique of SMR does not seem to be superior to another.

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Severe Thrombotic Complications in Congenital Afibrinogenemia: A Pathophysiological and Management Dilemma

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0036-1581103 ◽

2016 ◽

Vol 42 (05) ◽

pp. 577-582 ◽

Cited By ~ 11

Author(s):

Cristina Santoro ◽

Fulvio Massaro ◽

Salvatore Venosi ◽

Saveria Capria ◽

Erminia Baldacci ◽

...

Keyword(s):

Lower Limb ◽

Arterial Thrombosis ◽

Clinical Presentation ◽

Antiplatelet Agents ◽

Low Molecular Weight ◽

Hemorrhagic Diathesis ◽

Platelet Activity ◽

Left Lower Limb ◽

Congenital Afibrinogenemia ◽

Thrombotic Complications

Congenital afibrinogenemia (CA) is a disease characterized by a complex pathophysiology, involving both the procoagulant and fibrinolytic systems, as well as platelet activity. Although hemorrhagic diathesis represents the most frequent clinical presentation of this disorder, severe thrombotic events can occur. It is not yet clear if these events are strictly related to the disease itself or to the fibrinogen replacement therapy. Different hypotheses on the pathophysiological mechanisms have been proposed. It is well known that fibrinogen/fibrin has a role in the downregulation of thrombin generation in plasma. In the absence of circulating fibrinogen, this “antithrombin” activity is missing and plasma thrombin levels rise; this excess of thrombin could promote clotting of the infused fibrinogen, initiating the thrombotic process. Furthermore, the observation of impaired plasmin generation in the plasma of CA patients has raised the hypothesis of a fibrinolytic system deficiency. We report the case of a CA male patient who at the age of 36 years experienced an arterial thrombosis in his left lower limb. Despite an aggressive medical treatment with low-molecular-weight heparin, fibrinolytic and antiplatelet agents, the arterial thrombosis progressed to the obstruction of the whole left arterial district and the patient underwent the amputation of the left lower limb. This case demonstrates the complexity of pathophysiology and clinical management of a “so-called” bleeding disorder as CA.

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Bleeding complications and antithrombotic treatment in 264 pregnancies in antiphospholipid syndrome

Lupus ◽

10.1177/0961203318787032 ◽

2018 ◽

Vol 27 (10) ◽

pp. 1679-1686 ◽

Cited By ~ 5

Author(s):

C M Yelnik ◽

M Lambert ◽

E Drumez ◽

V Le Guern ◽

J-L Bacri ◽

...

Keyword(s):

Antiphospholipid Syndrome ◽

Major Bleeding ◽

Pregnancy Outcomes ◽

Prospective Cohort ◽

Retrospective Cohort ◽

Post Partum ◽

Bleeding Complications ◽

Minor Bleeding ◽

Increased Risk ◽

History Of

Purpose The purpose of this study was to evaluate the safety of antithrombotic treatments prescribed during pregnancy in patients with antiphospholipid syndrome (APS). Methods This international, multicenter study included two cohorts of patients: a retrospective French cohort and a prospective US cohort (PROMISSE study). Inclusion criteria were (1) APS (Sydney criteria), (2) live pregnancy at 12 weeks of gestation (WG) with (3) follow-up data until six weeks post-partum. According to APS standard of care, patients were treated with aspirin and/or low-molecular weight heparin (LMWH) at prophylactic (pure obstetric APS) or therapeutic doses (history of thrombosis). Major bleeding was defined as abnormal blood loss during the pregnancy and/or post-partum period requiring intervention for hemostasis or transfusion, or during the peripartum period greater than 500 mL and/or requiring surgery or transfusion. Other bleeding events were classified as minor. Results Two hundred and sixty-four pregnancies (87 prospectively collected) in 204 patients were included (46% with history of thrombosis, 23% with associated systemic lupus). During pregnancy, treatment included LMWH ( n = 253; 96%) or low-dose aspirin ( n = 223; 84%), and 215 (81%) patients received both therapies. The live birth rate was 89% and 82% in the retrospective and prospective cohorts, respectively. Adverse pregnancy outcomes occurred in 28% of the retrospective cohort and in 40% of the prospective cohort. No maternal death was observed in either cohort. A combined total of 45 hemorrhagic events (25%) occurred in the retrospective cohort, but major bleeding was reported in only six pregnancies (3%). Neither heparin nor aspirin alone nor combined therapy increased the risk of hemorrhage. We also did not observe an increased rate of bleeding in the case of a short interval between last LMWH (less than 24 hours) or aspirin (less than five days) doses and delivery. Only emergency Caesarean section was significantly associated with an increased risk of bleeding (odds ratio (OR) 5.03 (1.41–17.96); p=.016). In the prospective cohort, only one minor bleeding event was reported (vaginal bleeding). Conclusion Our findings support the safety of antithrombotic therapy with aspirin and/or LMWH during pregnancy in high-risk women with APS, and highlight the need for better treatments to improve pregnancy outcomes in APS. PROMISSE Study ClinicalTrials.gov identifier: NCT00198068.

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New Oral Anticoagulants vs. Vitamin K Antagonists Among Patients With Cardiac Amyloidosis: Prognostic Impact

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.742428 ◽

2021 ◽

Vol 8 ◽

Author(s):

Eve Cariou ◽

Kevin Sanchis ◽

Khailène Rguez ◽

Virginie Blanchard ◽

Stephanie Cazalbou ◽

...

Keyword(s):

Vitamin K ◽

Cardiac Amyloidosis ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Bleeding Complications ◽

Prognostic Impact ◽

Transthyretin Amyloidosis ◽

Increased Risk ◽

All Cause Mortality ◽

History Of

Background: Atrial arrhythmia (AA) is common among patients with cardiac amyloidosis (CA), who have an increased risk of intracardiac thrombus. The aim of this study was to explore the prognostic impact of vitamin K-antagonists (VKA) and direct oral anticoagulants (DOAC) in patients with CA.Methods and Results: 273 patients with CA and history of AA with long term anticoagulation−69 (25%) light chain amyloidosis (AL), 179 (66%) wild-type transthyretin amyloidosis (ATTRwt) and 25 (9%) variant transthyretin amyloidosis (ATTRv)–were retrospectively included between January 2012 and July 2020. 147 (54%) and 126 (46%) patients received VKA and DOAC, respectively. Patient receiving VKA were more likely to have AL with renal dysfunction, higher NT-proBNP and troponin levels. Patients with ATTRwt were more likely to receive DOAC therapy. There were more bleeding complications among patients with VKA (20 versus 10%; P = 0.013) but no difference for stroke events (4 vs. 2%; P = 0.223), as compared to patients with DOAC. A total of 124 (45%) patients met the primary endpoint of all-cause mortality: 96 (65%) and 28 (22%) among patients with VKAs and DOACs, respectively (P < 0.001). After multivariate analysis including age and renal function, VKA was no longer associated with all-cause mortality.Conclusion: Among patients with CA and history of AA receiving oral anticoagulant, DOACs appear to be at least as effective and safe as VKAs.

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