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This review focuses on significant advances in the field of pediatric hemostasis and thrombosis, with a focus on published studies within the past decade. The evaluation and management of patients with excessive bleeding remain cornerstones of consultative hematology. We will describe the development of validated bleeding assessment tools relevant to pediatric practice, laboratory advances in the evaluation of von Willebrand disease, and a shift in clinical practice regarding the interpretation of normal coagulation studies in patients with significant bleeding phenotypes. There have also been critical advances in the management of hemostatic disorders. This review highlights new treatment paradigms in hemophilia and the rise of multidisciplinary medical homes for women living with bleeding disorders. Given the continued increase in the incidence of thrombosis, particularly in the hospital setting, a full call to arms against pediatric venous thromboembolism is now essential. We will describe recently completed clinical trials of direct oral anticoagulants in children and adolescents and ongoing work to elucidate the appropriate duration of therapy for children with provoked thrombosis. Recent work regarding the prevention of pediatric venous thromboembolism is highlighted, including studies of thromboprophylaxis and the development of risk prediction models for hospital-acquired thrombosis. Finally, we review advances in our understanding of thrombotic sequelae and the need for continued refinement of our evaluation tools. Despite the significant advances in pediatric hemostasis and thrombosis over the past decade, many unanswered questions remain for the next generation of investigators.

We describe a complex case of liver transplant in a 70-year-old male patient with no known history of coronary artery disease, normal preoperative left ventricular function, and negative preoperative cardiac workup who developed progressive intra-operative left ventricular myocardial dysfunction secondary to class I acute myocardial infarction, ultimately requiring intraoperative intra-aortic balloon pump insertion to optimize myocardial perfusion. Management of myocardial ischemia was complicated by bleeding in the setting of coagulopathy necessitating correction. Once hemostasis was achieved, the patient immediately underwent coronary angiography and bare metal stent placement in the mid-left anterior descending coronary artery for an acute plaque rupture.

Introduction Thromboembolic events occur due to an imbalance in the hemostasis and some factors associated with this condition can be inherited. In order to evaluate the frequency of genotypes considered to be common hereditary risk factors for thrombophilia associated with venous thrombosis (g.1691G > A and g.20210G > A) and hyperhomocysteinemia (g.677C > T and g.1298A > C), samples from voluntary healthy blood donors at the Hospital de Clinicas de Porto Alegre were tested. Methods We examined 325 blood samples from blood donors collected from October 2017 to July 2018. Blood was collected on filter paper and the DNA was extracted for single nucleotide polymorphisms (SNPs) analysis using the qualitative real time polymerase chain reaction. Results The calculated frequencies of each genetic variant in heterozygosity were 4% for the FV gene (g.1691G > A), 4% for the F2 gene (g.20210G > A) and 42% and 39% for methylenetetrahydrofolate reductase (MTHFR), g.677C > T and g.1298A > C, respectively. Only the genetic variants of MTHFR were found in homozygosity, with frequencies of 14% and 6% (g.677C > T and g.1298A > C), respectively. Discussion Altogether, these results describe the frequencies of genetic variants associated with venous thrombosis and hyperhomocysteinemia in the analyzed group and are important to enhance our current knowledge about the genetic profiles of Brazilian blood donors.

Purpose – determine the characteristics of changes of procoagulant, anticoagulant and fibrinolytic links of the hemostatic system in patients with hypertension in combination with coronary heart disease. Materials and methods. 127 people were examined - 14 healthy (control), 61 patients with stage II hypertension with concomitant coronary heart disease (group 2), 52 hypertensive patients with stage III with concomitant coronary heart disease (group 3). There were evaluated indicators of hemostasis system: thrombin time, activated partial thromboplastin time, prothrombin index, soluble fibrin monomer complex, fibrinogen, protein C, antithrombin III of, and the time of XII-dependent fibrinolysis. Results. Patients on both study groups SFMC content significantly higher than the control group. SFMC content in patients with stage II hypertension with concomitant coronary heart disease exceed normative value of 3 times, and in the group of hypertensive patients with stage III with with concomitant coronary heart disease of 3.65 times. The content of fibrinogen in the third group of patients exceeded the indicators of the control group by 27.6%, the difference was significant (p

Background Use of percutaneous mechanical circulatory support has grown exponentially. Vascular complications remain a growing concern and best practices for device removal do not exist. We describe a novel post-closure technique for the next generation Impella CP removal and immediate hemostasis . Methods This study is a single center, retrospective, exploratory analysis of 11 consecutive patients receiving an Impella CP for either high-risk PCI or cardiogenic shock and then referred for post-closure compared to 20 patients receiving manual compression for Impella CP removal between 2017 and 2019. Results Mean age range was 62.7–65.4 years and 50–65% male between groups. Average duration of Impella CP treatment ranged from 3.4 to 5.2 days. Patients referred for post-closure had significantly lower rates of all-cause adverse vascular events (0% versus 40%; n = 0/11 versus n = 8/20; p = 0.01). There was no significant difference in BARC 3 or greater bleeding, transfusion requirement, hospitalization duration or intensive care duration between removal strategies. Conclusion The novel post-closure technique may significantly reduce vascular complications associated with device removal and may improve clinical outcomes for these critically ill patients.

Percutaneous endoscopic gastrostomy (PEG) is a common method for providing long-term enteral nutrition to patients. PEG tube placement and removal are relatively safe; generally, a PEG tube can be removed using gentle traction, and excessive bleeding is rare. The over-the-scope clip system is a new device that can be used for gastrointestinal hemostasis and for closing gastrointestinal fistulae. In the present case, a 68-year-old male patient had to remove the PEG tube because of persistent leakage around the PEG tube. Although it was gently removed using traction, incessant bleeding continued, with a Rockall score of 5 points, even after hemocoagulation was attempted. An over-the-scope clip device was used to achieve hemostasis and fistula closure.

Objective Harmonic Focus (Ethicon, Johnson and Johnson, Cincinnati, OH, USA), LigaSure Small Jaw (Medtronic, Covidien Products, Minneapolis, MN, USA), and Thunderbeat Open Fine Jaw (Olympus, Japan) are electrosurgical instruments used widely in head and neck surgery. The study aims to compare device malfunctions, adverse events to patients, operative injuries, and interventions related to Harmonic, LigaSure, and Thunderbeat use during thyroidectomy. Methods The US Food and Drug Administration's Manufacture and User Facility Device Experience (MAUDE) database was queried for adverse events associated with Harmonic, LigaSure, and Thunderbeat from January 2005 to August 2020. Data were extracted from reports pertaining to thyroidectomy. Results Of the 620 adverse events extracted, 394 (63.5%) involved Harmonic, 134 (21.6%) LigaSure, and 92 (14.8%) Thunderbeat. The reported device malfunctions most frequently associated with Harmonic was damage to the blade (110 (27.9%)), LigaSure was inappropriate function (47 (43.1%)), Thunderbeat was damage to the tissue or Teflon pad (27 (30.7%)), respectively. Burn injury and incomplete hemostasis were the most commonly reported adverse events. The operative injury reported most frequently when using Harmonic and LigaSure was burn injury. No operator injuries were reported with Thunderbeat use. Conclusion The most frequently reported device malfunctions were damage to the blade, inappropriate function, and damage to the tissue or Teflon pad. The most frequently reported adverse events to patients was a burn injury and incomplete hemostasis. Interventions aimed at improving physician education may help reduce adverse events attributed to improper use.

Transoral robotic surgery (TORS) is becoming widely used in Japan, and information on postoperative hemorrhage is needed. We treated a patient who developed a second massive postoperative hemorrhage on Day 35 post-TORS. The 69-year-old man was diagnosed with p16-positive, T1N1M0 stage I cancer of the anterior wall of the oropharynx. Curative treatment began with right neck dissection. The external carotid artery and its branches were not ligated. One month after right neck dissection, TORS was conducted. On Day 23 post-TORS, the patient was brought to the emergency room due to pharyngeal bleeding. Hemorrhage was stopped by reclosing the site with Z-shaped silk sutures. Severe hemorrhage recurred on Day 35 post-TORS. The patient went into hemorrhagic shock. Tracheostomy was immediately performed. The neck dissection wound was then opened and the external carotid artery clamped. Hemostasis was confirmed transorally, but the hemorrhage site was again sutured with Z-shaped silk sutures to stop the bleeding. The patient was discharged on Day 58 post-TORS. Even in hindsight, this hemorrhage would have been difficult to prevent with better local treatment. This means that using transcervical arterial ligation together with TORS is appropriate from the perspective of making every effort to prevent potentially fatal postoperative hemorrhage.

External aortic compression has been investigated as a treatment for non-compressible truncal haemorrhage in trauma patients. We sought to systematically gather and tabulate the available evidence around external aortic compression. We were specifically interested in its ability to achieve hemostasis and aid in resuscitation of traumatic arrest and severe shock and to consider physiological changes and adverse effects. A scoping review approach was chosen due to the highly variable existing literature. We were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, using the specific extension for scoping reviews. Searches were done on PubMed and Scopus databases in October 2020. We found that a range of studies have investigated external aortic compression in a variety of settings, including case reports and small case series, porcine hemorrhage models and effects on healthy volunteers. External aortic compression for postpartum hemorrhage in a single center provided some evidence of effectiveness. Overall the level of evidence is limited, however, external aortic compression does appear able to achieve cessation of distal blood flow. Furthermore, it appears to improve many relevant physiological parameters in the setting of hypovolemic shock. Application for more than 60 minutes appears to cause increasingly problematic complications. In conclusion we find that the role of external aortic compression warrants further research. The intervention may have a role as a bridge to definitive treatment of noncompressible truncal haemorrahge.

Research evaluating hemostatic agents for the treatment of clinically significant bleeding has been hampered by inconsistency and lack of standardized primary clinical trial outcomes. Clinical trials of hemostatic agents in both cardiac surgery and mechanical circulatory support, such as extracorporeal membrane oxygenation and ventricular assist devices, are examples of studies that lack implementation of universally accepted outcomes.A subgroup of experts convened by the National Heart, Lung, and Blood Institute and the US Department of Defense developed consensus recommendations for primary outcomes in cardiac surgery and mechanical circulatory support.For cardiac surgery the primary efficacy endpoint of total allogeneic blood products (units vs mL/kg for pediatric patients) administered intraoperatively and postoperatively through day 5 or hospital discharge is recommended. For mechanical circulatory support outside the perioperative period the recommended primary outcome for extracorporeal membrane oxygenation is a 5-point ordinal score of thrombosis and bleeding severity adapted from the Common Terminology Criteria for Adverse Events version 5.0. The recommended primary endpoint for ventricular assist device is freedom from disabling stroke (Common Terminology Criteria for Adverse Events AE ≥ grade 3) through day 180.The proposed composite risk scores could impact the design of upcoming clinical trials and enable comparability of future investigations. Harmonizing and disseminating global consensus definitions and management guidelines can also reduce patient heterogeneity that would confound standardized primary outcomes in future research.

Background and Aims Standard coagulation tests such as prothrombin time, activated partial thromboplastin time, and international normalized ratio are determined by liver-synthesized coagulation factors. Despite an increased international normalized ratio, patients with cirrhosis are in a “rebalanced” state of hemostasis as the concomitant effect of reduced protein C, protein S, and thrombomodulin is not evaluated in standard coagulation tests. The cell-based model of hemostasis indicates additional mechanisms such as systemic inflammation, sepsis, and organ failures tip the delicate coagulation balance to an anticoagulant type in acute-on-chronic liver failure. In acute liver failure, thrombin generation and platelet function remain intact despite a marked prolongation in prothrombin time. We aimed to explain the principles, application, and utility of viscoelastic tests such as thromboelastography, rotational thromboelastometry, and Sonoclot. Methods We reviewed the available literature from MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trial with the search terms 'coagulation', 'cirrhosis', 'acute-on-chronic liver failure', 'thromboelastography', 'thromboelastometry' and 'sonoclot' for cross sectional studies, cohort studies and randomized trials Results The point-of-care viscoelastic tests provide actionable targets for correcting the coagulation defect in a patient with bleeding and provide evidence-based algorithms for use in liver disease. A limitation of these tests is the inability to assess vessel injury and endothelial elements. Conclusion Global coagulation tests provide a comprehensive estimate of coagulation in vitro; however, their use has only been validated in the setting of liver transplantation. Newer guidelines for hemostatic resuscitation are now accepting these POC tests, but additional data are required to validate their use as standard of care.

Despite the fact that acetylsalicylic acid (ASA) is the "gold" standard for the prevention of cardiovascular complications in patients with coronary heart disease (CAD), a number of patients still have risks of atherothrombosis. In the present study, the antithrombotic effect of ASA in patients with CAD was assessed in platelet-rich plasma (PRP) using integral tests of the hemostasis study: the T-TAS system (Total Thrombus-formation Analysis System) and the thrombin generation test (TGT). The study involved 34 patients with stable CAD (11 women, 23 men) and people (15 women, 18 men) in the control group. As a result of assessing the activity of thrombus formation using the T-TAS system, a significant decrease in the area under the curve (AUC10) was found in the group with CAD patients compared with the control (135.6 [88.0-222.3] and 260.5 [217.3-301.9], respectively, p.Nesmotria na to, chto atsetilsalitsilovaia kislota (ASK) iavliaetsia zolotym standartom profilaktiki serdechno-sosudistykh oslozhneniĭ (SSO) u bol'nykh ishemicheskoĭ bolezn'iu serdtsa (IBS), vse zhe u riada patsientov sokhraniaiutsia riski aterotromboza. V nastoiashchem issledovanii provedena otsenka antitromboticheskogo éffekta ASK u patsientov s IBS s pomoshch'iu integral'nykh testov issledovaniia gemostaza: sistemy T-TAS (total thrombus-formation analysis system) i testa generatsii trombina (TGT) v bogatoĭ trombotsitami plazme (PRP — platelet rich plasma). Obsledovano 34 patsienta so stabil'noĭ IBS (11 zhenshchin, 23 muzhchiny) i 33 cheloveka (15 zhenshchin, 18 muzhchin) gruppy kontrolia. V rezul'tate otsenki aktivnosti tromboobrazovaniia s pomoshch'iu sistemy T-TAS obnaruzheno znachimoe snizhenie ploshchadi pod krivoĭ (AUC10) v gruppe s IBS po sravneniiu s kontrol'noĭ (135,6 [88,0-222,3] i 260,5 [217,3-301,9], r.

Distal radial artery access (DRA) is recommended as the preferred approach over the traditional proximal radial artery access (TRA) for coronary procedures; however, there are limited randomized controlled trials (RCTs) that compared the 2. We conducted an updated meta-analysis of all RCTs from inception to July 26, 2021, that compared DRA versus TRA in patients who underwent coronary procedures. The statistical analysis was performed using a random effect model to calculate risk ratios (RRs) with 95% confidence intervals (CIs). A total of 5 RCTs were included with a total of 1,005 patients. A pooled analysis of the data showed that the rate of successful cannulation was similar between the 2 arms (RR 0.85, 95% CI 0.68 to 1.07, p = 0.16, I2 = 94%). The rate of radial artery spasm significantly favored the DRA arm as compared with TRA (RR 0.51, 95% CI 0.34 to 0.75, p = 0.0007, I2 = 0%). Significantly more patients from the DRA arm required alternative arterial access. Moreover, the DRA group had an insignificantly decreased rates of radial artery occlusion (RR 0.24, 95% CI 0.05 to 1.20, p = 0.08, I2 = 46%) and early discharge after transradial stenting of coronary arteries access-site hematomas (RR 0.52, 95% CI 0.18 to 1.149, p = 0.22, I2 = 0%). The mean time for hemostasis was significantly shorter in the DRA arm (mean difference −6.64, 95% CI −10.37 to −2.90, p = 0.0005, I2 = 88%). In conclusion, DRA should be considered as a viable, effective, and safe arterial access method for patients who underwent coronary procedures.

Atherosclerotic heart disease remains a major cause of morbidity and mortality worldwide. The past few decades have seen the emergence of chronic inflammation as a mediator of atherosclerosis. Although the heart and vascular system remain the organ systems most affected in the atherosclerotic process, chronic inflammation and ischemia trigger a systemic multi-organ response. The liver is a critical organ for systemic hemostasis and recent developments have established an important role of the liver in response to atherosclerosis and myocardial ischemia. In addition, the rapid emergence of systemic liver diseases has unraveled a pathophysiological link with heart disease with therapeutic implications. In this review, we explore the relationship between the liver and the heart in myocardial ischemia, describe epidemiological associations between various liver pathologies and coronary heart disease, and elucidate practical challenges in the clinical management of patients with concomitant coronary heart disease and hepatic abnormalities.

Management of coagulopathy in patients with advanced liver disease undergoing therapeutic endoscopic procedures is complex. Improvements in the understanding of hemostasis at a physiologic level have highlighted the inaccuracy of currently available clinical tests, like platelet count and prothrombin time, in estimating hemostasis in patients with cirrhosis. With identification of novel factors that contribute to bleeding risk in patients with cirrhosis, there is a dearth of clinical trial data that account for all potentially relevant factors and that examine interventions to reduce bleeding risk. Precise recommendations regarding transfusion strategies based on hemostatic test results in patients with cirrhosis are impractical.

The objective of this study was to quantify intraoperative bleeding in patients with cirrhosis and correlate it with clinical characteristics and laboratory coagulation tests.A case-control study was carried out with 74 patients with cirrhosis who were submitted to preoperative coagulation tests (complete blood count, platelet count, prothrombin time/international normalized ratio, thrombin time, activated partial thrombin time, platelet aggregation, fibrinogen, protein C, protein S, antithrombin, and von Willebrand factor level and activity). The levels of nitrogen compounds that can affect the platelet function were determined in saliva and blood by using automated enzymatic-colorimetric assays.Patients with cirrhosis had changes in almost all coagulation tests. The average volumes of intraoperative bleeding and blood lost per minute in the study group (5.36 mL/min and 0.19 mL/min, respectively) were greater than those in the control group (3.05 mL/min and 0.11 mL/min, respectively; P.05). In the control group, ascites (P = .012) and presence of periapical lesion (0.034) were positively correlated with bleeding (mL/min). With regard to coagulation tests and nitrogen compounds, only a positively moderate correlation with the platelet aggregation test was observed.No patients had hemorrhagic events and it was not possible to correlate a greater amount of bleeding with coagulation tests or nitrogen compounds in the study group.

Objective To clinically assess the socket healing after tooth extraction and the occurrence of intra- and postoperative complications in chronic kidney failure (CKF) patients on hemodialysis (HD) by comparing them to a control group. Study desing This is a prospective study involving 48 patients with CKF on HD (study group – SG) and 29 participants without CKF (control group – CG) undergoing tooth extractions. No prophylactic antibiotic was given to the participants. One calibrated dentist evaluated all individuals at 3, 7, 21, and 60 days after the tooth extractions and assessed hemostasis time, occurrence of local or distant infection, epithelization, and deposition of alveolar bone. Results In the SG, 87 teeth were extracted through 65 interventions, and in the CG, 76 teeth were extracted through 36 interventions. Bleeding beyond 30 minutes was observed in 12 interventions (18.5%) on SG participants and was controlled with local hemostatic agents. None of the groups had individuals presenting postoperative infectious complications at the surgical site or a distance. After 21 days, we observed delayed epithelialization in 29.9% (26/87) of the individuals of SG compared to 3.9% (3/37) of those of CG (P Conclusions Individuals with CKF on hemodialysis tend to heal up well following dental extractions. They did not have an increased risk of infectious complications after simple tooth extractions, but they showed prolonged bleeding events more often than controls. Additional research studies using larger sample sizes of patients with CKF on hemodialysis are needed to confirm our findings. Clinical relevance This pilot study contributes to dentists ability to provide better dental management for people with chronic kidney failure undergoing hemodialysis through understanding the course of healing following dental extractions.

Background/Aims: Recent reports suggest that the biliary self-expandable metallic stent (SEMS) is highly effective for maintaining hemostasis when endoscopic hemostasis fails in endoscopic retrograde cholangiopancreatography (ERCP)-related bleeding. We compared whether temporary SEMS offers better efficacy than angioembolization for refractory immediate ERCP-related bleeding.Methods: Patients who underwent SEMS placement or underwent angioembolization for bleeding control in refractory immediate ERCP-related bleeding were included in the retrospective analysis. We evaluated the hemostasis success rate, severity of bleeding, change in hemoglobin levels, amount of transfusion, and delay to the start of hemostasis.Results: A total of 27 patients with SEMS and 13 patients who underwent angioembolization were enrolled. More transfusions were needed in the angioembolization group (1.0±1.4 units vs. 2.5±2.0 units; p=0.034). SEMS failure was successfully rescued by angioembolization. The partially covered SEMS (n=23, 85.1%) was generally used, and the median stent-indwelling time was 4 days. The mean delay to the start of angioembolization was 95.2±142.9 (range, 9–491) min.Conclusions: Temporary SEMS had similar results to those of angioembolization (96.3% vs. 92.3%; p=0.588). Immediate SEMS insertion is considered a bridge treatment modality for immediate refractory ERCP-related bleeding. Angioembolization still has a role as rescue therapy when SEMS does not work effectively.

BACKGROUND: Venous varicosities are a relatively common finding during pregnancy. Rarely, varices can arise in the cervix and cause life-threatening maternal hemorrhage. This article offers an example of a patient who was diagnosed with bleeding cervical varices during pregnancy and summarizes the diagnosis and treatment strategies for the 20 other reported cases in the literature. METHODS: A PubMed literature search using the following terms was performed to gather data for the literature review: “bleeding” or “hemorrhage” and “cervical varices” or “cervical varix” or “cervical varicosities” and “pregnancy” or “obstetric” or “maternal.” Individual references cited in each article were also evaluated for inclusion in this review. RESULTS: A 50-year-old gravida 7 para 1 presented at 12 4/7 weeks with vaginal bleeding. Endo-vaginal ultrasound showed enhanced color Doppler signal in the endocervical canal. During a speculum exam, she was found to have active bleeding from ruptured cervical varicosities and required blood and fresh frozen plasma transfusion. Hemostasis was achieved with interrupted suture ligation. A McDonald cerclage was subsequently placed. She continued pregnant until delivery via cesarean section at 37 2/7 weeks. To date, there have only been 20 other reported cases of bleeding cervical varices during pregnancy. CONCLUSIONS: This case report and review of the literature highlight the importance of including bleeding cervical varices in the differential diagnosis of maternal hemorrhage and offer a treatment strategy if cervical varicosities are discovered during pregnancy.

У статті подано результати лікування 98 хворих на гострий панкреатит (ГП) середньої тяжкості. Хворі були розподілені на 2 групи: у 35 хворих (основна група) на ГП середньої тяжкості в комплексі лікування використовували еноксапарин у дозі 0,5 мг/кг підшкірно 1 раз на добу протягом 12–14 діб. Порівнювали результати лікування пацієнтів із ГП і хворих, які отримували подібне лікування, але без еноксапарину (63 хворі — група порівняння). Групи були тотожними за вихідними параметрами при надходженні до лікарні. Застосування еноксапарину у хворих на ГП середньої тяжкості сприяло покращенню показників гемостазу і мало протизапальний ефект.

The article analyzes the evidence and disputed points in the algorithm of the temporary bleeding stop in the prehospital phase using modern tourniquets. The paper provides a brief description of Combat Application Tourniquet, SWAT-Tourniquet as the most common ones. Both the immediate survival of victims in extreme conditions and the quality of later life due to the minimization of post-tourniquet complications (tourniquet syndrome, peripheral neuralgia, limb frostbite in the cold season) depend on the knowledge of the staff of emergency medical teams about the modern tourniquets (Combat Application Tourniquet, Special Operations Forces Tactical Tourniquet, Mechanical Advantage Tourniquet, Ratcheting Medical Tourniquet, SWAT-Tourniquet). More than 100 years of using rubber band tourniquet revealed its shortcomings, which necessitated the search for new solutions and analysis of the problems identified. In 2004, after extensive researches and field tests conducted by the United States Army Institute of Surgical Research, which analyzed 10 different models of tourniquets, specific models of tourniquets were identified recommended for the use in rescue services. In contrast to all other methods of temporary hemostasis, tourniquet stops the blood flow not only in the damaged great vessel, but also in all its collaterals. In the absence of oxygenated blood flow, metabolism occurs by anaerobic type. Exceeding the permissible time for applying a tourniquet, the limb accumulates oxidized products of metabolism that cause cytolysis. After removing a tourniquet, oxidized products enter the bloodstream, causing a sharp shift in the acid-base balance towards metabolic acidosis. Сytolysis products cause gene­ralized vasoplegia, and myoglobin released from the muscle fibers is filtered in the urine and under acidosis precipitated in the renal tubules causing acute renal failure. External bleeding is the leading cause of deaths among the wounded persons with damage to the great vessels of the limbs. Tourniquet — an effective mean of temporary homeostasis in massive bleeding from the wounds of the extremities, but the violation of algorithm for temporary bleeding stop in the prehospital phase can neutralize the positive effects of modern tourniquets. Bleeding from the wounds of the major vessels of the limbs in not less than 75 % of cases can be stopped by pressure bandage. When using modified compression bandages together with modern local hemostatic agents, the frequency of the effective application of gentle methods of hemostasis in the prehospital phase will increase even more.

Background: Transcatheter aortic valve replacement is an established treatment option for patients with severe symptomatic aortic stenosis and is most commonly performed through the transfemoral access route. Percutaneous access site closure can be achieved using dedicated plug-based or suture-based vascular closure device (VCD) strategies, but randomized comparative studies are scarce. Methods: The CHOICE-CLOSURE trial (Randomized Comparison of Catheter-based Strategies for Interventional Access Site Closure during Transfemoral Transcatheter Aortic Valve Implantation) is an investigator-initiated, multicenter study, in which patients undergoing transfemoral transcatheter aortic valve replacement were randomly assigned to vascular access site closure using either a pure plug-based technique (MANTA, Teleflex) with no additional VCDs or a primary suture-based technique (ProGlide, Abbott Vascular) potentially complemented by a small plug. The primary end point consisted of access site– or access-related major and minor vascular complications during index hospitalization, defined according to the Valve Academic Research Consortium-2 criteria. Secondary end points included the rate of access site– or access-related bleeding, VCD failure, and time to hemostasis. Results: A total of 516 patients were included and randomly assigned. The mean age of the study population was 80.5±6.1 years, 55.4% were male, 7.6% of patients had peripheral vascular disease, and the mean Society of Thoracic Surgeons score was 4.1±2.9%. The primary end point occurred in 19.4% (50/258) of the pure plug-based group and 12.0% (31/258) of the primary suture-based group (relative risk, 1.61 [95% CI, 1.07–2.44], P =0.029). Access site– or access-related bleeding occurred in 11.6% versus 7.4% (relative risk, 1.58 [95%CI: 0.91–2.73], P =0.133) and device failure in 4.7% versus 5.4% (relative risk, 0.86, [95% CI, 0.40–1.82], P =0.841) in the respective groups. Time to hemostasis was significantly shorter in the pure plug-based group (80 [32–180] versus 240 [174–316] seconds, P Conclusions: Among patients treated with transfemoral transcatheter aortic valve replacement, a pure plug-based vascular closure technique using the MANTA VCD is associated with a higher rate of access site– or access-related vascular complications but a shorter time to hemostasis compared with a primary suture-based technique using the ProGlide VCD. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04459208.

Background. Uterine fibroid is one of the most common diseases in gynaecological practice accounting from 32 to 70 % according to various authors. In 80 % of cases, fibroids are observed in women of reproductive age. Laparoscopic myomectomy is one of the main methods of surgical treatment for uterine fibroids in wo­men of reproductive age. A large number of advantages of this method of surgical treatment in many cases lead to underestimation of the existing risks such as the risk of thrombosis in women with elevated body mass index (BMI). The purpose of this study is to detect the risk of thrombosis in adequate comprehensive thromboprophylaxis of patients with elevated BMI in the perioperative period of laparoscopic myomectomy using an instrumental method of diagnosis such as low-frequency piezoelectric blood viscometer. Materials and methods. Patients aged 30–45 years undergoing laparoscopic myomectomy (n = 60) were exa­mined. They were divided into 3 groups depending on the BMI and thromboprophylaxis method. Group 1 (n = 16) included women with the BMI 30 kg/m2, who were treated with enoxaparin thromboprophylaxis at a dose of 2,000 anti-Xa IU/0.2 ml subcutaneously (at the BMI of 30–40 kg/m2) and 4,000 anti-Xa IU/0.4 ml subcutaneously (at the BMI > 40 kg/m2). Third group (n = 26) included individuals with the BMI > 30 kg/m2 who received enoxaparin and pentoxifylline for thromboprophylaxis. Results. The low-frequency piezoelectric blood viscometry revealed statistically significant (p < 0.05) deviations from the reference values of the coagulogram towards structural (increased maximum clot density) and chronometric hypercoagulation (acceleration of the time of formation of fibrin-platelet structure T5, shift of the blood clotting time T3 to the left, an increase in the intensity of coagulation drive), elevated thrombin activity (an increase in the constant of thrombin activity, a decrease in T2 time), activation of vascular-platelet hemostasis (reduced period of T1 reaction onset, increased intensity of contact coagulation), inhibition of the lytic activity (a decrease in the intensity of retraction and lysis of the clot) in groups 2 and 3. On the first day after surgery in groups 2 and 3, there was a significant increase (compared to preoperative indicators) in the chronometric indicators such as T1, T2 and T5; a decrease in the structural indicator of maximum clot density, as well as a significant decrease in the constant of thrombin activity, intensity of contact coagulation, which confirms the effectiveness of antithrombotic therapy. However, group 2 reported an increase in the activity of vascular-platelet hemostasis, higher intensity of contact coagulation compared to group 3, shorter T1 and T2 time, and the constant of thrombin activity was higher. On the 5th day after surgery, a normocoagulation trend of hemostatic potential was observed in all groups of patients. Conclusions. The use of low-frequency piezoelectric blood viscometry allows reliably and quickly assessing the kinetics of thrombosis formation., Актуальність. Міома матки — одне з найпоширеніших захворювань у гінекологічний практиці та становить, за даними різних авторів, від 32 до 70 %. У 80 % випадків міома спостерігається у жінок репродуктивного віку. Одним з основних методів хірургічного лікування міоми матки у жінок репродуктивного віку є лапароскопічна міомектомія. Велика кількість переваг даного методу хірургічного лікування призводить в багатьох випадках до недооцінки наявного ризику, такого як тромбонебезпека у жінок із підвищеним індексом маси тіла (ІМТ). Мета даного дослідження — виявлення стану тромбонебезпеки для проведення адекватної комплексної тромбопрофілактики пацієнток із підвищеним індексом маси тіла в періопераційному періоді при лапароскопічній міомектомії, використовуючи інструментальний метод діагностики — низькочастотний п’єзоелектричний гемовіскозиметр. Матеріали та методи. Пацієнтки 30–45 років, які підлягають лапароскопічній міомектомії (n = 60). Пацієнтки були розподілені на 3 групи залежно від величини індексу маси тіла та вибору методу тромбопрофілактики. До 1-ї групи (16 пацієнток) увійшли хворі з ІМТ < 30 кг/м2, яким медикаментозна тромбопрофілактика не проводилась. До 2-ї групи (18 пацієнток) увійшли хворі з ІМТ > 30 кг/м2, які з метою тромбопрофілактики отримували еноксапарин в дозі 2000 анти-Ха МО/0,2 мл підшкірно (при ІМТ 30–40 кг/м2) та 4000 анти-Ха МО/0,4 мл підшкірно (при ІМТ > 40 кг/м2). До 3-ї групи (26 пацієнток) увійшли хворі з ІМТ > 30 кг/м2, які з метою тромбопрофілактики отримували еноксапарин та пентоксифілін. Результати. За даними низькочастотного вібраційного п’єзоелектричного гемовіскозиметра були виявлені статистично вірогідні (р

Aim: Feedback activation of factor XI (FXI) by thrombin is believed to play a critical role in the amplification phase of thrombin generation and to contribute to thrombosis development and hemostasis. However, the activation of FXI by thrombin has been shown in vitro to require a cofactor. In this study, the role of thrombin in activated FXI (FXIa) formation in vivo is investigated. Methods: The study population comprised probands in whom coagulation activation was triggered by low-dose (15 µg/kg) recombinant activated factor VII (rFVIIa, n =89), of whom 34 with (VTE+) and 45 without a history of venous thromboembolism (VTE−), and patients undergoing major orthopedic surgeries ( n =45). FXIa was quantified via an enzyme capture assay using a monoclonal FXI-specific antibody. Thrombin formation was monitored using an oligonucleotide-based enzyme capture assay and the thrombin activation markers prothrombin fragment 1＋2 (F1＋2) and thrombin–antithrombin complex (TAT). Results: In the rFVIIa cohort, FXIa and thrombin remained below their lower limit of quantification of 3.48 and 1.06 pmol/L, respectively. By contrast, during the surgeries, median FXIa levels increased from 3.69 pmol/L pre-operatively to 9.41 pmol/L mid-operatively ( P =4·10 −4 ) and remained significantly elevated 24 h thereafter, with 9.38 pmol/L ( P =0.001). Peak levels of F1+2 were comparable in the VTE+, VTE−, and surgery cohort (235, 268, and 253 pmol/L), whereas peak TAT levels were higher in the surgery cohort (53.1, 33.9, and 147.6 pmol/L). Conclusions: Under in vivo conditions, the activation of FXI requires specific local features that are present at the wounded site including potential cofactors of thrombin.

von Willebrand disease (VWD) is the most common inherited bleeding disorder known in humans. Accurate and timely diagnosis presents numerous challenges.These evidence-based guidelines of the American Society of Hematology (ASH), the International Society on Thrombosis and Haemostasis (ISTH), the National Hemophilia Foundation (NHF), and the World Federation of Hemophilia (WFH) are intended to support patients, clinicians, and other health care professionals in their decisions about VWD diagnosis.ASH, ISTH, NHF, and WFH established a multidisciplinary guideline panel that included 4 patient representatives and was balanced to minimize potential bias from conflicts of interest. The Outcomes and Implementation Research Unit at the University of Kansas Medical Center (KUMC) supported the guideline-development process, including performing or updating systematic evidence reviews up to 8 January 2020. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subsequently subject to public comment.The panel agreed on 11 recommendations.Key recommendations of these guidelines include the role of bleeding-assessment tools in the assessment of patients suspected of VWD, diagnostic assays and laboratory cutoffs for type 1 and type 2 VWD, how to approach a type 1 VWD patient with normalized levels over time, and the role of genetic testing vs phenotypic assays for types 2B and 2N. Future critical research priorities are also identified.

Patients with CKD display a significantly higher risk of cardiovascular and thromboembolic complications, with around half of patients with advanced CKD ultimately dying of cardiovascular disease. Paradoxically, these patients also have a higher risk of hemorrhages, greatly complicating patient therapy. Platelets are central to hemostasis, and altered platelet function resulting in either platelet hyper- or hyporeactivity may contribute to thrombotic or hemorrhagic complications. Different molecular changes have been identified that may underlie altered platelet activity and hemostasis in CKD. In this study, we summarize the knowledge on CKD-induced aberrations in hemostasis, with a special focus on platelet abnormalities. We also discuss how prominent alterations in vascular integrity, coagulation, and red blood cell count in CKD may contribute to altered hemostasis in these patients who are high risk. Furthermore, with patients with CKD commonly receiving antiplatelet therapy to prevent secondary atherothrombotic complications, we discuss antiplatelet treatment strategies and their risk versus benefit in terms of thrombosis prevention, bleeding, and clinical outcome depending on CKD stage. This reveals a careful consideration of benefits versus risks of antiplatelet therapy in patients with CKD, balancing thrombotic versus bleeding risk. Nonetheless, despite antiplatelet therapy, patients with CKD remain at high cardiovascular risk. Thus, deep insights into altered platelet activity in CKD and underlying mechanisms are important for the optimization and development of current and novel antiplatelet treatment strategies, specifically tailored to these patients who are high risk. Ultimately, this review underlines the importance of a closer investigation of altered platelet function, hemostasis, and antiplatelet therapy in patients with CKD.

von Willebrand disease (VWD) is the most common inherited bleeding disorder. The management of patients with VWD who are undergoing surgeries is crucial to prevent bleeding complications. We systematically summarized the evidence on the management of patients with VWD who are undergoing major and minor surgeries to support the development of practice guidelines. We searched Medline and EMBASE from inception through October 2019 for randomized clinical trials (RCTs), comparative observational studies, and case series that compared maintaining factor VIII (FVIII) levels or von Willebrand factor (VWF) levels at >0.50 IU/mL for at least 3 days in patients undergoing major surgery, and those with options for perioperative management of patients undergoing minor surgery. Two authors screened and abstracted data and assessed the risk of bias. We conducted meta-analyses when possible. We evaluated the certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. We included 7 case series for major surgeries and 2 RCTs and 12 case series for minor surgeries. Very-low-certainty evidence showed that maintaining FVIII levels or VWF levels of >0.50 IU/mL for at least 3 consecutive days showed excellent hemostatic efficacy (as labeled by the researchers) after 74% to 100% of major surgeries. Low- to very-low-certainty evidence showed that prescribing tranexamic acid and increasing VWF levels to 0.50 IU/mL resulted in fewer bleeding complications after minor procedures compared with increasing VWF levels to 0.50 IU/mL alone. Given the low-quality evidence for guiding management decisions, a shared-decision model leading to individualized therapy plans will be important in patients with VWD who are undergoing surgical and invasive procedures.

We reviewed 7 patients with unsuccessful endoscopic hemostasis using covered self-expandable metal stent (CSEMS) placement for post-endoscopic sphincterotomy (ES) bleeding. ES with a medium incision was performed in 6 and with a large incision in 1 patient. All but 1 of them (86%) showed delayed bleeding, warranting second endoscopic therapies followed by CSEMS placement 1–5 days after the initial ES. Subsequent CSEMS placement did not achieve complete hemostasis in any of the patients. Lateral-side incision lines (3 or 9 o’clock) had more frequent bleeding points (71%) than oral-side incision lines (11–12 o’clock; 29%). Additional endoscopic hemostatic procedures with hemostatic forceps, hypertonic saline epinephrine, or hemoclip achieved excellent hemostasis, resulting in complete hemostasis in all patients. These experiences provide an alert: CSEMS placement is not an ultimate treatment for post-ES bleeding, despite its effectiveness. The lateral-side of the incision line, as well as the oral-most side, should be carefully examined for bleeding points, even after the CSEMS placement.

Objective This study aimed to assess the effect of endometrioma surgery on ovarian reserve by measuring anti-Mullerian hormone (AMH) levels. Methods This systematic review and meta-analysis included observational studies and randomized clinical trials published in English referenced in MEDLINE, SCOPUS and Cochrane (1982-2019). We included studies that reported AMH levels in the pre and post-operative period of patients undergoing laparoscopic surgery for endometrioma. Preoperative AMH was defined as the baseline AMH; short term AMH was measured no later than a month after surgery; medium term AMH was measured between one and six months after surgery; and long-term AMH was measured six or more months after surgery. Results Thirty-six studies met the inclusion criteria. A significant decrease was observed in short, medium and long-term post-operative AMH levels when compared with baseline AMH. However, there were no differences between short and long-term post-operative AMH levels, suggesting a non-significant recovery after one year of follow-up. A significant decrease in post-operative AMH was observed in bilateral endometriomas compared with unilateral cases. In addition, patients with endometriomas presented a significant decline in post-operative AMH compared with patients with other benign ovarian conditions. The decrease in post-operative AMH was significantly greater in bilateral cystectomy when compared with vaporization with bipolar energy or laser. We also observed a greater decrease in post-operative AMH with bipolar energy hemostasis compared with suture and hemostatic agents. These results should be taken with caution due to the high heterogeneity of the studies analyzed. Conclusions Endometrioma surgery has a deleterious effect on short, medium, and long-term post-operative AMH levels. Bilateral endometriomas and endometriomas greater than 7 cm have been associated with greater decreases in AMH. The mechanical resection of healthy tissue and the inflammatory damage on the ovarian cortex might explain the diminishing of ovarian reserve.

Early diagnosis and prompt definitive management of acute compartment syndrome (ACS) are paramount in preventing the significant morbidity associated with compartment syndrome. The diagnosis of compartment syndrome can be difficult, given the pain associated with the procedure in the immediate postoperative period. Obesity, anticoagulation, postoperative epidural infusion, and prolonged operative time have been reported as risk factors for ACS. In addition to maintaining high clinical suspicion in patient with risk factors for ACS after joint replacement, emphasis on limiting modifiable risk factors should be practiced, including meticulous hemostasis, careful patient positioning, and limiting prolonged postoperative regional anesthesia when not required.

OBJECTIVES To verify the efficacy and safety of Red Dichromatic Imaging (RDI) in hemostatic procedures during endoscopic submucosal dissection (ESD). METHODS This is a multicenter randomized controlled trial of 404 patients who underwent ESD of the esophagus, stomach, colorectum. Patients who received hemostatic treatments by RDI during ESD were defined as the RDI group (n=204), and those who received hemostatic treatments by white light imaging (WLI) were defined as the WLI group (n=200). The primary endpoint was a shortening of the hemostasis time. The secondary endpoints were a reduction of the psychological stress experienced by the endoscopist during the hemostatic treatment, a shortened treatment time, and a non-inferior perforation rate, in RDI versus WLI. RESULTS The mean hemostasis time in RDI (n=860) was not significantly shorter than that in WLI (n=1049) (62.3±108.1 versus 56.2±74.6 seconds; p=0.921). The median hemostasis time was significantly longer in RDI than in WLI (36.0 (18.0-71.0) versus 28.0 (14.0-66.0) seconds; p=0.001) in a sensitivity analysis. The psychological stress was significantly lower in RDI than in WLI (1.71±0.935 versus 2.03±1.038; p

Background and Aims: Acute liver failure (ALF) is characterized by significant changes in the hemostatic system and by systemic inflammation. The formation of neutrophil extracellular traps (NETs), in which an activated neutrophil expels its DNA, histones, and granular enzymes, such as myeloperoxidase (MPO), has been associated with immune-mediated and thrombotic diseases. We hypothesized that formation of NETs in patients with ALF contributes to progression of disease.Approach and Results: A total of 676 patients with ALF (international normalized ratio [INR], >= 1.5) or severe acute liver injury (ALI; INR, >= 2.0) were recruited from the U.S. ALF Study Group Registry between 2011 and 2018, of whom 308 patients (45.6%) had acetaminophen-induced ALF. Up to 21 days after admission, 483 patients (71.5%) survived without liver transplantation (LT). Levels of cell-free DNA (cfDNA) and the specific NET marker MPO-DNA complexes were measured in plasma samples obtained on admission and compared to levels in healthy controls. In addition, liver tissue obtained at transplantation of 20 ALF patients was stained for NETs. Levels of cfDNA were 7.1-fold, and MPO-DNA complexes 2.5-fold, higher in patients with ALF compared to healthy controls. cfDNA levels were not associated with 21-day transplant-free survival, but were higher in those patients with more-severe disease on admission, as reflected by various laboratory and clinical parameters. MPO-DNA levels were 30% higher in patients with ALF who died or required urgent LT. Liver tissue of ALF patients stained positive for NETs in 12 of 18 evaluable patients.Conclusions: Here, we provide evidence for NET formation in patients with ALF. Elevated plasma levels of MPO-DNA complexes in patients with ALF were associated with poor outcome, which suggests that NET formation contributes to disease progression.

Background Platelets circulate in the blood of healthy individuals for approximately 7-10 days regulated by finely balanced processes of production and destruction. As platelets are anucleate we reasoned that their protein composition would change as they age and that this change would be linked to alterations in structure and function. Objective To isolate platelets of different ages from healthy individuals to test the hypothesis that changes in protein content cause alterations in platelet structure and function. Methods Platelets were separated according to thiazole orange fluorescence intensity as a surrogate indicator of mRNA content and so a marker of platelet age and then subjected to proteomics, imaging, and functional assays to produce an in-depth analysis of platelet composition and function. Results Total protein content was 45±5% lower in old platelets compared to young platelets. Predictive proteomic pathway analysis identified associations with 28 biological processes, notably higher hemostasis in young platelets whilst apoptosis and senescence were higher in old platelets. Further studies confirmed platelet ageing was linked to a decrease in cytoskeletal protein and associated capability to spread and adhere, a reduction in mitochondria number, and lower calcium dynamics and granule secretion. Conclusions Our findings demonstrate changes in protein content are linked to alterations in function as platelets age. This work delineates physical and functional changes in platelets as they age and serves as a base to examine differences associated with altered mean age of platelet populations in conditions such as immune thrombocytopenia and diabetes.

Factor XI (FXI) deficiency (hemophilia C or Rosenthal disease) was first described in the 1950s in a multigenerational family experiencing bleeding related to surgery and dental procedures. Managing patients with FXI deficiency presents several challenges, including a lack of correlation of bleeding symptoms with FXI activity levels, the large volume of fresh frozen plasma required to achieve hemostatic FXI levels, lack of availability of FXI concentrate in certain regions of the world, and the inherent thrombotic risk associated with replacement therapy. This article summarizes presentation, diagnosis, and management of patients with FXI deficiency in a variety of clinical settings.

Platelets are commonly transfused either therapeutically or prophylactically to maintain hemostasis. Most platelet transfusions are used to manage patients with hematologic malignancies. Although platelet transfusion guidelines have been published, platelet transfusion practices are still heterogeneous. Platelet transfusion guidelines partly lack recommendations or differ in the platelet threshold recommendations in some clinical situations. This article reviews platelet transfusions focusing on transfusion guidelines and platelet thresholds in different clinical settings.

Various topical hemostatic agents can help induce coagulation at the liver cut surface. However, hemostasis is usually ineffective in controlling bleeding. We present a case of rescue fibrin glue-infiltrating hemostasis combined with hepatorrhaphy to manage intractable postoperative bleeding from the liver cut surface. The case was a 56-year-old male patient with hepatocellular carcinoma in hepatitis B virus-associated cirrhotic liver. The patient was administered warfarin because of graft replacement of the ascending aorta and hemi-arch one year earlier. After warfarin was discontinued, segment VII partial hepatectomy was performed according to standard procedures. However, considerable bleeding occurred during and after hepatectomy. Bleeding from the liver cut surface was controlled over one hour using surface coagulation and topical application of four kinds of hemostatic agents. However, active abdominal bleeding led to reoperation soon after the hepatectomy. During the reoperation, we identified diffuse oozing from the edge of the liver cut surface which was difficult to control. Thus, we performed direct parenchymal injection of fibrin glue at the bleeding points using 12 fibrin glue kits which induced complete hemostasis. Because the patient would undergo anticoagulation again soon after the operation, we also performed hepatorrhaphy. The patient recovered uneventfully after the reoperation. He has been doing well for six months without complications. In conclusion, fibrin glue-infiltrating hemostasis effectively controlled intractable bleeding from the hepatic cut surface in our case. Thus, it can be considered as an optional method for rescue hemostasis.

Surgical removal of tumor is the primary treatment of choice for glomus tympanicum (GT). However, because the tumor has abundant blood flow, bleeding control is crucial, and preoperative embolization may be performed. Here, we report the case of a 46-year-old female who visited our hospital with a complaint of right pulsatile tinnitus. A red pulsatile mass was found in the right tympanic cavity, and she was diagnosed with class B1 GT and subsequently underwent surgical treatment. We judged that bleeding could be controlled by intratympanic cavity manipulation alone and decided to perform transmeatal tumor resection without preoperative arterial embolization. After creating a tympanomeatal flap and performing an atticotomy, some pieces of Spongel(®) were inserted between the tumor and the tympanic wall. The Spongel(®) absorbed the blood and created a space between the tumor and tympanic wall, which allowed for the insertion of the tip of the Vesalius(®) handpiece to coagulate the tumor. The coagulation caused the tumor to shrink, thereby widening the space and allowing for further resection. Although the surgical manipulation caused bleeding, complete resection was achieved by the application of Spongel(®) and coagulation with Vesalius(®). Since the tip of the Vesalius(®) was not burned, hemostasis was successfully achieved, and the operation proceeded while maintaining a clear field of view. There was little bleeding and no postoperative complications. The patient was discharged on the sixth postoperative day. One year after surgery, pure tone audiometry showed no change in the level of bone conduction. Spongel(®) and Vesalius(®) are useful tools that allow to safely perform surgeries even in narrow spaces such as the tympanic cavity.

BACKGROUND OR PURPOSE We report our single-center experience with percutaneous left atrial appendage closure (LAAC) in patients with non-valvular atrial fibrillation (NVAF) and primary hemostasis disorders (HD). METHODS Consecutive patients with primary HD who underwent a percutaneous LAAC were included. Baseline characteristics, procedural data, and clinical outcomes were prospectively collected and compared with the overall LAAC cohort without HD. RESULTS Since 2013, among 229 LAAC, 17 patients (7%) had a primary HD: thrombocytopenia (n = 5), myelodysplastic syndrome (n = 6), von Willebrand syndrome (n = 4), type A hemophilia (n = 1), and dysfibrinogenemia (n = 1). The HD population's age ranged from 61 to 87 years, and the median CHA2DS2VASc was 5. Periprocedural plasmatic management was required in 47% of patients. The immediate LAAC implantation success rate was 100%. Patients received a direct oral anticoagulant (DOA) (n = 9), dual antiplatelet (n = 6), aspirin (n = 1), or no therapy (n = 1) during the first six postoperative weeks, followed with single antiplatelet (n = 16) or no therapy (n = 1) during lifelong. After 20 months, the technical success rate and procedural success rate were 100% and 94%. Zero device-/procedure-related complication and only one life-threatening bleeding occurred. Compared to patients without HD (n = 212), a baseline history of bleeding was less frequent (53% vs 91%, p

ObjectiveThe aim of this study was to perform a systematic review and meta-analysis of existing evidence on the role of hot saline irrigation in patients undergoing functional endoscopic sinus surgery and its impact on the visibility of the surgical field.MethodA search of PubMed, Cochrane, Ovid databases and Google Scholar was performed.ResultsThree randomised controlled trials were included. Pooled meta-analysis demonstrated a statistically significant better visibility of the surgical field, and a reduction in total blood loss and operating time during functional endoscopic sinus surgery in the hot saline irrigation group compared with the room temperature irrigation group. Subgroup analysis of studies that did not use vasoconstrictors showed a significant reduction in total blood loss and operating time.ConclusionThis is the first systematic review that addresses hot saline irrigation for haemostasis in functional endoscopic sinus surgery. The results suggest that hot saline irrigation in functional endoscopic sinus surgery for chronic rhinosinusitis may significantly improve visibility of the surgical field, reduce total blood loss by 20 per cent and decrease operating time by 9 minutes. However, there are limitations of the study because of the significant heterogeneity of the methods, quality and size of the studies.

Background: The mortality of freshwater fish due to stress during various production manipulations is a severe problem, which requires a thorough understanding of the basic mechanisms involved, including the hemostasis system. Therefore, on the application level, the study of blood clotting can perform fish coagulopathies diagnostics and develop practical preventive and therapeutic anticoagulation methods for fish farming. Aim: The goal of this research was a comparative assessment of the reaction of some hemostasis parameters of two commercial fish species, carp Cyprinus carpio and tilapia Oreochromis niloticus, to the stress of different duration induced by corticosteroids. Methods: The fishes were divided into three groups: chronically stressed (induction by betamethasone), acutely stressed (induction by dexamethasone), and control animals with blood taken from the caudal hemal canal before hormone treatment(by dexamethasone and betamethasone), then 7 and 21 days after. Results and Discussion: Changes in the following parameters were studied: thrombin time, prothrombin time, activated partial thromboplastin time, the concentration of fibrinogen, soluble fibrin monomer complexes, antithrombin. It was found that both hormone-induced stress and handling stress associated with blood sampling strongly increased blood clotting ability in carps (prothrombin time decrease by 78,5-86,1%, fibrinogen increase by 12,7-100%, thrombin time decrease by 83,4-85%, and antithrombin III decreases by 15,3-21,7%), while in tilapias, acceleration of blood clotting by intrinsic and extrinsic pathways were recorded by the end of the experiment only in fishes with imitation of chronic stress (prothrombin time decrease by 76,8%, activated partial thromboplastin time decrease by 20,0%, and 2,3 multiplying soluble fibrin monomer complexes). Conclusions: It was concluded that the adaptive mechanisms of the tilapia (Oreochromis niloticus) organism allowed the clotting function to recover in most cases by the end of the experiment in all groups of fish, in contrast to carps (Cyprinus carpio).

Introduction: The high incidence of thrombotic events in patients with COVID-19 affects health care worldwide and results in an increased workload in haemostasis laboratories due to more frequent testing of D-dimer, haemostatic parameters and anti-Xa tests. However, the impact of this increase in assay requests on the quality of performance in haemostasis laboratories remains unclear. In this study, the impact of the COVID-19 pandemic on the quality of performance and management of haemostasis laboratories was evaluated.Methods: The impact on the quality of performance was studied using external quality assessment data from 2019 to 2020 derived from ECAT surveys. A questionnaire was sent to Dutch haemostasis laboratories to identify challenges and management strategies. Furthermore, the number of assays performed in 2019 and 2020 was supplied by four Dutch hospitals, located in regions with different disease incidence.Results: No differences in response rate nor the quality of the measurements were observed between the EQA surveys in 2019 and 2020. The questionnaire results showed a large increase of >25% in the number of test requests for anti-Xa, D-dimer and fibrinogen assays in 2020 compared to 2019. Extreme peaks in test requests were also observed in the four evaluated hospitals. Additionally, 84% of the respondents indicated that they had experienced increased work pressure, and increased sick leave was observed in 71% of the participating laboratories.Conclusions: The enormous increase in test requests, especially for D-dimer assays and anti-Xa activity, did not affect the quality of performance within haemostatic laboratories during the COVID-19 pandemic.

Pregnancies complicated by the placenta praevia are associated with an increased risk of massive obstetric bleeding and high rates of hysterectomy which are often caused by the placenta accreta.This was a cohort study carried out between 2014 and 2020 in 532 women with abnormal placental localization and attachment. The placental attachment spectrum (PAS) disorder diagnosis was confirmed during the surgery and by the histology results in 164/532 participants. Depending on the surgical approach during the Cesarean delivery, patients were divided into three groups. In Group 1 (PAS was observed in 30.8% of the placenta praevia cases, and in 93.3% was associated with the presence of a uterine scar. Women with the placenta praevia and PAS had a significantly higher number of past deliveries (

International audience; Due to concomitant changes in pro- and anti-coagulant mechanisms, patients with liver dysfunction have a “rebalanced hemostasis”, which can easily be tipped toward either a hypo- or a hypercoagulable phenotype. Clinicians are often faced with the question whether patients with chronic liver disease undergoing invasive procedures or surgery and those having active bleeding require correction of the hemostasis abnormalities. Conventional coagulation screening tests, such as the prothrombin time/international normalized ratio and the activated partial thromboplastin time have been demonstrated to have numerous limitations in these patients and do not predict the risk of bleeding prior to high-risk procedures. The introduction of global coagulation assays, such as viscoelastic testing (VET), has been an important step forward in the assessment of the overall hemostasis profile. A growing body of evidence now suggests that the use of VET might be of significant clinical utility to prevent unnecessary infusion of blood products and to improve outcomes in numerous settings. The present review discusses the advantages and caveats of both conventional and global coagulation assays to assess the risk of bleeding in patients with chronic liver disease as well as the current role of transfusion and hemostatic agents to prevent or manage bleeding.

Objective. Coil embolization (CE) for coronary artery perforation (CAP) has not been thoroughly evaluated. This study aimed to evaluate the extent of myocardial damage and impact on cardiac function after CE for CAP. Methods. A total of 110 consecutive patients treated with CE for CAP were retrospectively identified. The degree of myocardial damage and impact on cardiac function were evaluated. Results. Forty-nine (44.5%) cases involved chronic total occlusions. A guidewire was the cause of perforation in 97 (88.2%) patients. The success rate of CE was 98.2%. Almost all patients were prescribed either antiplatelet drugs or anticoagulant medication or both. Patients with perforation types III and IV were found to be prone to creatinine kinase (CK) elevation and epicardial main vessel perforation, thereby causing myocardial damage. No changes were noted in the ejection fraction (EF) in patients with type V distal perforation and collateral channel perforation, while patients with perforation of the epicardial main vessel may show impaired cardiac function afterward. Conclusions. CE is safe and effective for treating CAP, especially when collateral channels and distal vessels are involved. Meanwhile, efforts should be taken to prevent CAP in epicardial main vessels since it may be difficult to treat with CS and cause myocardial damage when bailed out with CE leading to vessel sacrifice. We found that it was not necessary to change the anticoagulant regimen after CE owing to its ability to achieve robust hemostasis.

The correlation relationships between hemostatic potential parameters and concentrations of molecular markers of the hemostasis system: soluble fibrin (sf), D-dimer (DD), fibrinogen (Fg) and protein C (PC) in patients with stenosis of coronary artery 6 months after coronary angioplasty have been investigated. It was found three directions of changes in the state of the patients hemostasis system: an increasing in fibrinolytic activity (C) ~18% of patients; an increasing in coagulative activity (B) ~31% of patients; and maintaining of the balance between coagulation and fibrinolysis (A) ~51% of patients. In patients with signs of stenosis without angina pectoris, a strong Pearson correlation was shown between the half-life of the clot and the overall hemostatic potential (OHP) (r = 0.75, P << 0.05), a moderate relationship between concentrations of sf and D-dimer (r = 0.67, P

BackgroundProthrombotic and inflammatory variables decrease after obesity surgery. The contact activation system may be a common denominator of these changes.ObjectiveTo characterize the contact system before and 6 months after Roux-en-Y gastric bypass (RYGB) and to evaluate associations with changes (post-surgery minus pre-surgery) in metabolic variables.MethodsWomen (n = 42) and men (n = 18) with obesity underwent RYGB, and measures of kallikrein generation, factor XII (FXII), prekallikrein, high molecular weight kininogen (HK), and C1 esterase inhibitor (C1-inh) were determined before and 6 months after surgery. Associations were evaluated using correlation and multivariate regression analyses.ResultsAfter RYGB, the endogenous kallikrein potential (EKP), peak kallikrein generation, FXII, and prekallikrein were reduced, and kallikrein generation lag time was prolonged (all p < 0.0005). Before and after RYGB, absolute values of EKP, lag time, and peak kallikrein generation correlated consistently with contact system proteins (range of correlation coefficients (rS): −0.43 to −0.28 and 0.24 to 0.45 (pre-surgery); −0.43 to −0.30 and 0.28 to 0.50 (post-surgery)). RYGB-associated changes in EKP correlated with C1-inh (rS = −0.29, p = 0.025), but also with triglycerides (rS = 0.34, p = 0.007) and cholesterol (rS = 0.28, p = 0.029), and independently associated with changes in C1-inh (β = −0.40) and triglycerides (β = 0.39). Changes in C1-inh associated with reductions in body weight (β = −0.39) and HbA1c (β = 0.38).ConclusionThe contact system was affected 6 months after RYGB. Absolute values of kallikrein generation before and after RYGB correlated with contact system proteins, whereas changes after RYGB associated with changes in C1-inh and metabolic variables.