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Objective: To assess the impact of the updated ACR/EULAR APS classification criteria on two large research cohorts., Methods: Consecutive patients who tested persistently positive for at least one aPL in the last three years were enrolled. The first APS Sydney index event was considered and computed for the comparison between Sydney and 2023 APS criteria. When computing the 2023 APS criteria, additional manifestations were also considered., Results: The cohort comprised 249 patients (185 with APS and 64 aPL carriers according to Sydney criteria). The 185 patients had as first index event venous thrombosis in 55 cases (29.8%), arterial thrombosis in 63 (34%) and pregnancy morbidity in 67 (36.2%). When applying the updated criteria, 90 subjects (48.7%) failed to reach the composite score of the new criteria. The percentage of thrombotic APS per Sydney criteria decreased from 47.3% to 34.9% because of high cardiovascular risk in 23 cases, IgM aPL profile in six cases and in two patients for both reasons. Patients with pregnancy morbidity decreased from 26.9% to 3.2% (39 cases of recurrent early pregnancy loss and 20 of fetal losses). Consequently, the percentage of aPL carriers increased from 26% to 61%. When looking at the disease evolution at follow-up, 32 additional patients out of 90 (35.6%) fulfilled the new APS criteria, after developing additional clinical manifestation following index event., Conclusion: When applying the new APS criteria to our research cohorts, not-negligible differences exist in patients' classification. A multidisciplinary approach will be mandatory to assess the impact of the new criteria on research and, ultimately, patients' care., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Evaluation of tolerability is increasingly relevant for patients with haematological malignancies treated with chronically administered therapies. Adverse events from these agents might affect the ability of patients to tolerate treatment over time. Conventional toxicity tables that include the incidence of high-grade adverse events, defined by the Common Terminology Criteria for Adverse Events, do not provide information on the time profile of these adverse events or reflect the continuous, lower grade symptomatic toxicities that are particularly relevant to treatment tolerability for patients living with indolent disease. Modern approaches to the evaluation and reporting of toxicity that capture the tolerability of treatment to the patient are imperative. In this Viewpoint, we present a focused, pilot, and longitudinal Toxicity over Time analysis of adverse events from lenalidomide and lenalidomide with rituximab in patients with follicular lymphoma treated in the CALGB 50401 (Alliance; NCT00238238) trial to define the trajectory of adverse events and quantify the burden of continuous, low-grade events. Toxicity over Time analyses provided clinically relevant descriptions of neutropenia and fatigue trajectories caused by lenalidomide that were not identified by standard analysis of the maximum grade events defined by the Common Terminology Criteria for Adverse Events. Systematic, rigorous incorporation of patient-reported outcomes in clinical trials will be crucial to our understanding of the tolerability of chronically administered therapies in patients with haematological malignancies., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Platelets are anucleate cells in blood whose principal function is to stop bleeding by forming aggregates for hemostatic reactions. In addition to their participation in physiological hemostasis, platelet aggregates are also involved in pathological thrombosis and play an important role in inflammation, atherosclerosis, and cancer metastasis. The aggregation of platelets is elicited by various agonists, but these platelet aggregates have long been considered indistinguishable and impossible to classify. Here we present an intelligent method for classifying them by agonist type. It is based on a convolutional neural network trained by high-throughput imaging flow cytometry of blood cells to identify and differentiate subtle yet appreciable morphological features of platelet aggregates activated by different types of agonists. The method is a powerful tool for studying the underlying mechanism of platelet aggregation and is expected to open a window on an entirely new class of clinical diagnostics, pharmacometrics, and therapeutics., Competing Interests: YZ, AY, CL, CH, HK, YW, SY, CS, YY No competing interests declared, KG is a shareholder of two cell analysis startups (CYBO and Cupido)., (© 2020, Zhou et al.)

We observed different temporal patterns of HeartMate II left ventricular assist device (LVAD) thrombosis regarding clinical manifestations and lactate dehydrogenase (LDH) trends. We propose nomenclature for classification of LVAD thrombosis and compare patient characteristics and outcomes in each pattern of LVAD thrombosis. We reviewed electronic medical records of 362 consecutive HeartMate II devices implanted at Cleveland Clinic from October 2008 to July 2014. We categorized clinical courses of confirmed device thrombosis based on clinical manifestations and LDH patterns. Patients' characteristics, clinical variables, and outcomes were collected for comparison. From a total of 19 confirmed device thromboses, we categorized the patterns of thrombosis into three distinctive types; abrupt thrombosis (Type 1), subacute thrombosis (Type 2), and asymptomatic hemolysis (Type 3). Abrupt thrombosis (Type 1) tended to be the most morbid clinical course with acute-onset thrombosis at 56.5 (interquartile range: 44-71) days, all New York Heart Association functional class III or IV at presentation. Death and need for surgical intervention were not different in each pattern. Asymptomatic hemolysis had unique comorbidities of preexisting cardiac thrombi and preoperative bacteremia. Confirmed LVAD thrombosis has different patterns of clinical presentation and each pattern of thrombosis has unique characteristics and clinical manifestations.

Objective: The aim of this study was to explore a new treatment strategy for left renal vein tumor thrombus directed at the thrombus level and the therapeutic effect of robotic surgery. Materials and Methods: Fifteen patients with left renal cell carcinoma with renal vein tumor thrombus (Mayo level 0) who underwent robotic radical nephrectomy and thrombectomy from July 2013 to July 2017 were included in this series. If the left renal vein thrombus transcended the superior mesenteric artery (SMA), the thrombus was classified as level 0b, the patient was positioned right side up for thrombectomy and repositioned left side up for nephrectomy, and angioembolization of left renal artery was necessary; otherwise, the thrombus was classified as level 0a and the patient was positioned left side up for both nephrectomy and thrombectomy. Baseline, perioperative, and follow-up data were analyzed. Results: Of all 15 patients, 10 had a level 0a tumor thrombus and 5 had a level 0b tumor thrombus. For level 0a patients, median operating time was 130 minutes, median estimated blood loss was 125 mL, with no patient receiving transfusion, and median hospital stay was 3.5 days. For level 0b patients, median operating time was 180 minutes, median estimated blood loss was 250 mL, with one patient receiving transfusion, and median hospital stay was 5 days. No perioperative complications or positive surgical margins occurred. For level 0a patients, one patient with preexisting lumbar vertebral metastasis died during a median follow-up of 39 months. For level 0b patients, all patients were alive at a median follow-up of 16.5 months. Conclusions: Our initial experience shows that the new treatment strategy for left renal vein tumor thrombus with the SMA as a dividing landmark directed at the thrombus level is safe and feasible. A larger cohort of level 0b patients and longer-term follow-up are needed to further assess the strategic advantages.

Background: Endovenous heat-induced thrombosis (EHIT) is a thrombus that extends from an ablated saphenous vein into the common femoral vein after endovenous radiofrequency ablation (RFA)., Objective: To investigate the incidence, progression, treatment, and risk factors associated with EHIT-2 or greater after RFA., Materials and Methods: This retrospective study included patients diagnosed with symptomatic superficial venous incompetence that were treated by RFA of the great saphenous vein or anterior accessory saphenous vein during the July 2012 to December 2016 study period. Duplex ultrasound scanning was performed at 1 week, 1 month, 3 months, and every year after RFA to detect EHIT., Results: A total of 317 legs from 274 patients were included. The incidence of EHIT-2 or greater was 7.0%, including 5.4% EHIT-2, 1.3% EHIT-3, and 0.3% EHIT-4. No symptomatic pulmonary embolism was found. The independent risk factors for EHIT-2 or greater were vein diameter (p = .027) and concomitant sclerotherapy (p = .037)., Conclusion: The risk factors found to be independently associated with EHIT-2 or greater were large vein size and concomitant sclerotherapy. Screening for EHIT should be performed in patients with one or both of these risk factors within 1 week after RFA and in patients with postoperative symptoms suggestive of venous thromboembolism.

Objectives: Thrombosis is a cause of morbidity in 4-15% of children who undergo pediatric cardiac surgery. Data on how to prevent this complication are sorely needed. We aimed to identify risk factors for thrombosis following pediatric cardiac surgery and determine if use of low molecular weight heparin prophylaxis is associated with a reduction in thrombosis risk., Design: Retrospective cohort study., Setting: Tertiary pediatric cardiovascular ICU., Patients: Patients who underwent cardiac surgery between June 2014 and December 2015., Interventions: None., Measurements and Main Results: Data from patients with venous or arterial thrombosis confirmed by radiologic studies were matched two-to-one to controls based on age, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality category, and gender. Thrombosis was detected in 33 patients (6.2%): 25 patients (76%) had venous thromboses, five patients (15%) had arterial thromboses, and three patients (9%) had both. Median time to thrombosis detection was 13 days (25-75%; 7-31 d). On multivariate analysis, which included adjustment for postoperative disease severity, fresh frozen plasma exposure was independently associated with thrombosis (odds ratio, 3.7; 95% CI, 1.4-9.4). Twenty-eight patients (85%) had central venous catheter-related thromboses. Low molecular weight heparin prophylaxis use in this subset of patients was not statistically different from controls (50% vs 45%, respectively; p = 0.47). On multivariable analysis, fresh frozen plasma exposure was also independently associated with central venous catheter-related thrombosis (odds ratio, 3.6; 95% CI, 1.2-10.6)., Conclusions: The occurrence of thrombosis after pediatric cardiac surgery at our institution was 6.2%, similar to what has been reported in other studies, despite frequent use of low molecular weight heparin. Further study is needed to determine the role of low molecular weight heparin for thromboprophylaxis and the relationship between fresh frozen plasma and thrombosis risk in children who undergo cardiac surgery.

Objectives: No standard classification exists for post-splenectomy thrombosis of splenic, mesenteric, and portal vein (PST-SMPv). The goal of this study was to review our institution's experience with PST-SMPv and to perform a systematic literature review., Methods: A retrospective review of all patients undergoing splenectomy from 1995-2016 at our institution was performed. Additionally, six databases and four grey literature websites were systematically searched. Splenectomy for pediatric patients or for trauma or portal hypertension related reasons were excluded., Results: Between 1995 and 2016, 229 patients (113; 49.3% males) underwent splenectomy for spleen related diseases at our institution. From 1895 to 2016, 1645 unique literature citations were identified. Twenty citations met our inclusion criteria. Data on 1745 splenectomized patients was compiled; PST-SMPv occurred in 141 (8.1%)., Conclusions: In our series, PST-SMPv developed in 6.6% of patients and the incidence of PST-SMPv after splenectomy in the literature ranges from 0.8 - 53.0%. A call for standardized reporting through a proposed classification is made., (Copyright © 2018 Elsevier Inc. All rights reserved.)

French hospital database, called Programme de Médicalisation des Systèmes d'Information (PMSI), covers all hospital stays in France (>66 million inhabitants). The aim of this study was to estimate the positive predictive values (PPVs) of primary diagnosis codes of peripheral arterial and venous thrombosis codes in the PMSI, encoded with the International Classification of Diseases, 10th revision. Data were extracted from the PMSI database of Toulouse University Hospital, south of France. We identified all the hospital stays in 2015 with a code of peripheral arterial or venous thrombosis as primary diagnosis. We randomly selected 100 stays for each category of thrombosis and reviewed the corresponding medical charts. The PPV of peripheral arterial thrombosis codes was 83.0%, 95% confidence interval (CI): 73.9-89.1, and the PPV of correct location of thrombosis was 81.0%, 95% CI: 72.2-87.5. The PPV of pulmonary embolism was 99.0%, 95% CI: 93.8-99.9. The PPV of peripheral venous thrombosis was 95.0%, 95% CI: 88.2-98.1, and the PPV of correct location of thrombosis was 85.0%, 95% CI: 76.7-90.7. Primary diagnoses of peripheral arterial and venous thrombosis demonstrated good PPVs in the PMSI., (© 2017 Société Française de Pharmacologie et de Thérapeutique.)

Objective: The goal of this study was to investigate the correlation between atherothrombotic aortic wall thrombus (AWT) and clinical outcomes in patients treated by fenestrated-branched endovascular aortic repair (F-BEVAR) and present a new classification system for assessment of AWT burden., Methods: The clinical data of 301 patients treated for pararenal and thoracoabdominal aortic aneurysms (TAAAs) by F-BEVAR was reviewed. The study excluded 89 patients with extent I to III TAAA because of extensive laminated thrombus within the aneurysm sac. Computed tomography angiograms were analyzed in all patients to determine the location, extent, and severity of atherothrombotic AWT. The aorta was divided into three segments: ascending and arch (A), thoracic (B) and renal-mesenteric (C). Volumetric measurements (cm 3 ) of AWT were performed using TeraRecon software (TeraRecon Inc, Foster City, Calif). These volumes were used to create an AWT index by dividing the AWT volume from the total aortic volume. A classification system was proposed using objective assessment of the number of affected segments, thrombus type, thickness, area, and circumference. Clinical outcomes included 30-day mortality, neurologic and gastrointestinal complications, renal events (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease [RIFLE]), and solid organ infarction., Results: The study included 212 patients, 169 men (80%) and 43 women (20%), with a mean age of 76 ± 7 years. A total of 700 renal-mesenteric arteries were incorporated (3.1 ± 1 vessels/patient). AWT was classified as mild in 98 patients (46%) and was considered moderate or severe in 114 (54%). There was one death (0.5%) at 30 days. Solid organ infarction was present in 50 patients (24%), and acute kidney injury occurred in 45 patients (21%) by RIFLE criteria. An association with higher AWT indices was found for time to resume enteral diet (P = .0004) and decline in renal function (P = .0003). Patients with acute kidney injury 2 by RIFLE criterion had significantly higher (P = .002) AWT index scores in segment B. Spinal cord injury occurred in three patients (1.4%) and stroke in four (1.9%), but were not associated with the AWT index. Severity of AWT using the new proposed classification system correlated with the AWT index in all three segments (P < .001). Any of the end points occurred in 35% of the patients with mild and in 53% of those with moderate or severe AWT (P = .016)., Conclusions: AWT predicts solid organ infarction, renal function deterioration, and longer time to resume enteral diet after F-BEVAR of pararenal and type IV TAAAs. Evaluation of AWT should be part of preoperative planning and decision making for selection of the ideal method of treatment in these patients., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate management and outcomes of thrombosis after pediatric cardiac surgery and stratify thrombi according to risk of short- and long-term complications to better guide therapeutic choices., Study Design: Retrospective review was performed of 513 thrombi (400 occlusive) diagnosed after 213 pediatric cardiac operations. Long-term outcomes over time were assessed with the use of parametric hazard regression models., Results: Serious complications and/or high-intensity treatment occurred with 17%-24% of thrombi depending on location, most commonly in thrombi affecting the cardiac and cerebral circulation. Bleeding complications affected 13% of patients; associated factors included thrombolytics (OR 8.7, P < .001), greater daily dose of unfractionated heparin (OR 1.25 per 5 U/kg/day, P = .03), and extracorporeal support (OR 4.5, P = .007). Radiologic thrombus persistence was identified in 30% ± 3% at 12 months; associated factors included extracorporeal support (hazard ratio [HR] 1.9, P = .003), venous (HR 1.7, P = .003), and occlusive thrombi at presentation (HR 1.8, P = .001); greater oxygen saturation before surgery (HR 1.13/10%, P = .05) and thrombi in femoral veins (HR 1.9, P = .001) were associated with increased hazard of resolution. Freedom from postthrombotic syndrome was 83% ± 4% at 6 years, greater number of persistent vessel segment occlusions (HR 1.8/vessel, P = .001) and greater fibrinogen at diagnosis (HR 1.1 per g/L, P = .02) were associated with increased hazard., Conclusions: Thrombosis outcomes after pediatric cardiac surgery remain suboptimal. Given that more intensive treatment would likely increase the risk of bleeding, the focus should be on both thrombosis-prevention strategies, as well as in tailoring therapy according to a thrombosis outcome risk stratification approach., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to analyse prevalence and type of pulmonary manifestations in patients with primary antiphospholipid syndrome (PAPS), their association to antiphospholipid antibody (aPL) type and localisation of peripheral vascular thrombosis, and possible relationship to existing cardiac manifestations., Methods: Our cross-sectional study comprised 318 PAPS patients, enrolled in the study as the Serbian APS Registry. aPL analysis included detection of aCL (IgG/IgM), ß2GPI (IgG/IgM) and LA, served to evaluate associations with cardiac and pulmonary manifestations., Results: In patients with pulmonary embolism and infarction, we observed significant prevalence of myocardial infarction (p=0.044), unstable angina pectoris (p=0.001), venous thrombosis (p=0.007) arterial thrombosis (p=0.0001), deep venous thrombosis of the low extremities (p=0.008), and superficial thrombophlebitis of the low extremities (p=0.023). Patients with primary pulmonary hypertension were more prone to unstable angina pectoris (p=0.009), while patients with secondary pulmonary hypertension were more prone to venous thrombosis (p=0.04) and deep venous thrombosis of the inferior extremities (p=0.04). Patients with pulmonary microthrombosis were more prone to unstable angina pectoris (p=0.026), arterial thrombosis (p=0.002), venous thrombosis (p=0.001), deep venous thrombosis of the inferior extremities (p=0.001), and superficial thrombophlebitis of the inferior extremities (p=0.001). The presence of LA was significantly higher in patients with pulmonary embolism and infarction (p=0.001), secondary pulmonary hypertension (p=0.032), and pulmonary microthrombosis (p=0.001)., Conclusions: Presence of LA was associated with distinct pulmonary manifestations in the Serbian APS cohort. There is a strong link between some cardiovascular and pulmonary manifestations in PAPS patients, suggesting complexity and evolutionary nature of PAPS.

Portal vein thrombosis (PVT) is commonly classified into acute (symptom duration <60 days and absence of portal carvernoma and portal hypertension) and chronic types. However, the rationality of this classification has received little attention. In this study, 60 patients (40 men and 20 women) with PVT were examined using contrast-enhanced computed tomography (CT). The percentage of vein occlusion, including portal vein (PV) and superior mesenteric vein (SMV), was measured on CT image. Of 60 patients, 17 (28.3%) met the criterion of acute PVT. Symptoms occurred more frequently in patients with superior mesenteric vein thrombosis (SMVT) compared to those without SMVT (p<0.001). However, there was no significant difference in PV occlusion between patients with and without symptoms. The frequency of cavernous transformation was significantly higher in patients with complete PVT than those with partial PVT (p<0.001). Complications of portal hypertension were significantly associated with cirrhosis (p<0.001) rather than with the severity of PVT and presence of cavernoma. These results suggest that the severity of PVT is only associated with the formation of portal cavernoma but unrelated to the onset of symptoms and the development of portal hypertension. We classified PVT into complete and partial types, and each was subclassified into with and without portal cavernoma. In conclusion, neither symptom duration nor cavernous transformation can clearly distinguish between acute and chronic PVT. The new classification system can determine the pathological alterations of PVT, patency of portal vein and outcome of treatment in a longitudinal study.

Accurate diagnostic assessment of suspected ipsilateral recurrent deep vein thrombosis (DVT) is a major clinical challenge because differentiating between acute recurrent thrombosis and residual thrombosis is difficult with compression ultrasonography (CUS). We evaluated noninvasive magnetic resonance direct thrombus imaging (MRDTI) in a prospective study of 39 patients with symptomatic recurrent ipsilateral DVT (incompressibility of a different proximal venous segment than at the prior DVT) and 42 asymptomatic patients with at least 6-month-old chronic residual thrombi and normal D-dimer levels. All patients were subjected to MRDTI. MRDTI images were judged by 2 independent radiologists blinded for the presence of acute DVT and a third in case of disagreement. The sensitivity, specificity, and interobserver reliability of MRDTI were determined. MRDTI demonstrated acute recurrent ipsilateral DVT in 37 of 39 patients and was normal in all 42 patients without symptomatic recurrent disease for a sensitivity of 95% (95% CI, 83% to 99%) and a specificity of 100% (95% CI, 92% to 100%). Interobserver agreement was excellent (κ = 0.98). MRDTI images were adequate for interpretation in 95% of the cases. MRDTI is a sensitive and reproducible method for distinguishing acute ipsilateral recurrent DVT from 6-month-old chronic residual thrombi in the leg veins., (© 2014 by The American Society of Hematology.)

Hemostasis is one of the most important process of physiology for human to live, in which hemostatic factors such as platelets and coagulation factors play an important role. On the other hand, thrombosis is often defined as a critical pathophysiology represented by myocardial infarction, cerebral infarction and pulmonary embolism, in which hemostatic factors also play a key part. Thus, these hemostatic factors have role in both good and bad aspects. Thrombosis is marked by sudden onset, irreversible dysfunction and recurrence, and classified to arterial and venous thromboses. The former is characterized by thrombus formation under fast blood flow, platelet activation, thrombus consisting most platelet and effectively treated by antiplatelet agents. The latter is characterized by thrombus formation under slow blood flow, coagulation activation, thrombus consisting most fibrin and effectively treated by anticoagulant agents. The classification of thrombosis is useful to choose appropriate therapy.

The antiphospholipid syndrome (APS) is defined by the occurrence of venous and arterial thromboses, often multiple, and recurrent fetal losses, frequently accompanied by a moderate thrombocytopenia, in the presence of antiphospholipid antibodies (aPL). Some estimates indicate that the incidence of the APS is around 5 new cases per 100,000 persons per year and the prevalence around 40-50 cases per 100,000 persons. The aPL are positive in approximately 13% of patients with stroke, 11% with myocardial infarction, 9.5% of patients with deep vein thrombosis and 6% of patients with pregnancy morbidity. The original classification criteria for the APS were formulated at a workshop in Sapporo, Japan, in 1998, during the 8th International Congress on aPL. The Sapporo criteria, as they are often called, were revised at another workshop in Sydney, Australia, in 2004, during the 11th International Congress on aPL. At least one clinical (vascular thrombosis or pregnancy morbidity) and one laboratory (anticardiolipin antibodies, lupus anticoagulant or anti-β2-glycoprotein I antibodies) criterion had to be met for the classification of APS., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Acute aortic syndromes are fatal medical conditions including classic acute aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer. Given the nonspecific symptoms and signs, a high clinical index of suspicion followed by an imaging study, namely transesophageal echocardiography, computed tomography, and magnetic resonance imaging (sensitivity 98-100% and specificity 95-100%), is a conditio sine qua non for prompt diagnosis of acute aortic syndromes. This article provides an overview of established and emerging approaches for the assessment of acute aortic syndromes, with focus on imaging and biomarkers. In this regard, D-dimer levels (cut-off: 500 ng/ml) may be useful to rule out aortic dissection, if used within the first 24 h after symptom onset.

Purpose of Review: In this article, an updated overview of risk factors and management of vascular complications in myeloproliferative neoplasms (MPN) is presented., Recent Findings: The rate of thrombosis in patients with polycythemia vera, essential thrombocythemia, and primary myelofibrosis is elevated and a risk-oriented therapeutic approach is recommended to avoid inappropriate exposure to cytotoxic drugs on one side or suboptimal treatment on the other. Established thrombosis risk factors are age and previous vascular events but novel disease-related determinants such as leukocytosis and JAK2V617F mutational status and/or mutational burden are now under active investigation. The theory that elevated platelet count increases thrombosis risk in these diseases is now challenged., Summary: Recent recommendations by the European Leukemia Net suggest that MPN patients should be stratified and treated according to conventional risk factors (age and previous events) and that baseline leukocytosis and JAK2V617F mutation should be considered once more information is available and when they have been eventually validated in prospective studies.

Objectives: This study sought to validate the sensitivity and specificity of the Academic Research Consortium's (ARC) classification of stent thrombosis., Background: Classification of stent thrombosis according to ARC criteria has become widely accepted. The criteria have not been validated against an autopsy standard., Methods: An autopsy registry of 139 subjects with prior coronary stenting underwent detailed histopathological analysis to assess for stent thrombosis. Based on clinical data only, cases were adjudicated according to ARC stent thrombosis criteria, including a proposed modification of the possible classification to include death beyond 30 days due only to sudden death or acute ischemia., Results: Autopsy results confirmed 51 cases as positive and 88 as negative for stent thrombosis. Clinical adjudication classified 105 cases as definite (10), probable (31), or possible (64) ARC stent thrombosis. Specificity was high for definite (99%) and definite plus probable (83%) criteria, but sensitivity was poor at 18% and 51%, respectively. Including the possible cases improved sensitivity to 92% but reduced specificity to 34% (58 false positives). The modified possible criteria eliminated 13 false positive cases (specificity = 49%) and was the best approximation of a hypothetical gold standard in a sensitivity analysis if late death represented at least 20% of all stent thrombosis cases., Conclusions: In a selected autopsy sample, restricting ARC stent thrombosis to definite or definite plus probable criteria results in substantial under-reporting of confirmed cases. Inclusion of a modified possible classification may provide the best estimate of late and very late stent thrombosis rates., (Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Carotid artery stenting is a rapidly evolving method for treating carotid artery disease. Various intraprocedural and postprocedural complications have been reported in the literature. However, the absence of a unified classification scheme for these complications makes it difficult, if not impossible, to study their precise incidence, predictors, and management. The aim of this article is to propose the first joint classification of periprocedural complications, to analyze their incidence and etiology, and suggest possible ways to manage and prevent them. This classification is intended to be used as a common platform for prompt recognition, evaluation, treatment, and universal study of the complications during carotid stenting procedures. For this purpose, the opinions of the major experts on carotid interventions worldwide were merged with all the available information reported in the English-language literature to present as accurately as possible the management and prevention of carotid stenting complications according to this proposed classification.

Introduction: Atherothrombosis can present as coronary artery disease (CAD) cerebrovascular disease (CVD) and peripheral arterial disease (PAD). It is unknown whether diabetics with CAD differ from those with other manifestations of atherothrombosis such as CVD or PAD regarding clinical characteristics, biochemical parameters, or medications., Material and Methods: The REACH (REduction of Atherothrombosis for Continued Health) registry evaluated 67 888 patients with established atherothrombosis or risk factors. Of 5 646 recruited German patients, 2 381 (42%) are diabetic. Of these 1 438 (60%) have CAD (either only CAD or in combination with CVD and/or PAD - CAD group) and 520 (22%) have other manifestations of atherothrombosis (either CVD or PAD or both - other manifestation group) and 18% have only risk factors. Differences between diabetics with CAD and diabetics with other manifestations of atherothrombosis were evaluated with multivariate models (79% male, 69+/-9 years, BMI 29+/-5 kg/m (2)) (SAS9.1)., Results: After correcting for age, sex and BMI, CAD patients receive (OR; 95% CI) more aspirin (1.5; 1.2-1.9; p=0.0002), statins (3.1; 2.6-3.7), beta-blockers (4.0; 3.8-4.8), diuretics (1.4; 1.2-1.6), ACE-inhibitors/ARBs (1.4; 1.2-1.7) and nitrates (8.8; 6.7-11.7) and significantly less often metformin (0.75; 0.61-0.93; p=0.01) with no differences concerning other antidiabetics. This resulted in significantly (p<0.05) lower blood-pressure (CAD 142/81 mmHg, other manifestations 145/82 mmHg) and LDL-cholesterol levels (CAD 108+/-37 mg/dl, other manifestations 123+/-37 mg/dl). Therefore more CAD patients reach LDL and blood-pressure-goals (CAD 47%/33%; other manifestations 30%/24%, respectively). Only few patients (CAD 7.1%, other manifestations 4.1%) reach all treatment goals. Furthermore, less CAD patients than patients with other manifestations of atherothrombosis are current smokers (11% vs. 22%)., Discussion: These data indicate considerable treatment differences between diabetics with CAD and those with other manifestations of atherothrombosis such as CVD or PAD. CAD patients are treated more intensively and therefore reach lower lipid and blood-pressure values., (J. A. Barth Verlag in Georg Thieme Verlag KG Stuttgart, New York.)

Background: Acute coronary syndromes are associated with platelet-rich, white thrombi (WT) and erythrocyte-rich, red thrombi (RT), but their ultrasonic characteristics are not well defined. To determine whether intravascular ultrasound (IVUS) could be used to detect specific characteristics of WT and RT, two experiments were performed., Methods: An in-vitro experiment evaluated five WT and five RT and an ex-vivo experiment evaluated thrombi from 17 atherosclerotic rabbits with disrupted plaques and overlying thrombi. Specimen were mounted flat, immersed in a saline bath and examined from the intimal surface. Thrombi were classified as WT (n = 69) or RT (n = 40) by gross inspection and histology. IVUS was performed using a 1 mm, 20 MHz transducer in a 4.8F catheter. Images were digitally converted and points integrated to account for angular and depth resolution. Sampling was performed at the water-tissue interface and four other sites at 0.3 mm radial depth increments. Signals from each depth were standardized by obtaining the ratio of each energy level to the level at the water-tissue interface., Results: The average energy ratio backscattered by RT was constant with increasing tissue depth while it attenuated for WT (P < 0.005; 2-way ANOVA). RT was less homogeneous and had more backscatter compared to WT. Light and electron microscopy corroborated these observations showing WT as densely homogenous and RT with loose cellular elements., Conclusion: WT may be detected by its attenuated ultrasound pattern versus a non-attenuated pattern for RT by IVUS. This technique has potential for characterizing WT and RT.

The aim of this review is to discuss current diagnostic approaches to, and classification of, patients presenting with thrombocytosis, in light of novel information derived from the discovery of specific molecular abnormalities in chronic myeloproliferative disorders (CMPD), which represent the most common cause of primary thrombocytosis. The JAK2V617F and the MPLW515L/K mutations have been found in patients with essential thrombocythemia, polycythemia vera, and primary myelofibrosis, and less frequently in other myeloproliferative disorders complicated by thrombocytosis. However, neither mutation is disease specific nor is it universally present in patients with elevated platelet counts due to a CMPD; therefore, distinguishing between reactive and primary forms of thrombocytosis, as well as among the different clinical entities that constitute the CMPD, still requires a multifaceted diagnostic approach that includes as a key step the accurate evaluation of bone marrow histology. The role of elevated platelet counts in thrombosis, which represent the predominant complication of CMPD,significantly affecting prognosis and quality of life as well as, paradoxically, in the pathogenesis of the hemorrhagic manifestations, will be discussed. Established and novel potential risk factors for thrombosis, including the clinical relevance of the JAK2V617F mutation, and current management strategies for thrombocytosis are also briefly discussed.

Because human studies concerning the effects of stearic acid on thrombotic tendency are inconsistent, we compared the effects of stearic acid with those of its unsaturated derivatives, oleic acid and linoleic acid. In this randomized, crossover study, 45 subjects (27 women and 18 men) consumed, in random order, 3 experimental diets, each for 5 wk. Diets contained approximately 38% of energy as fat. Dietary compositions were the same except for 7% of energy from stearic, oleic, or linoleic acids. At the end of each period, ex vivo and in vitro platelet aggregation, and variables of coagulation, fibrinolysis, and hematology were evaluated. In men, ex vivo platelet aggregation time as measured by filtragometry (P = 0.036 for diet effects) was favorably prolonged during consumption of the linoleic acid diet compared with the stearic acid diet (P = 0.040), but there was no difference with consumption of the oleic acid diet (P = 0.198). In vitro platelet aggregation induced by collagen and ADP, and variables of coagulation (factor VII amidolytic activity and concentrations of fibrinogen and prothrombin fragment 1 and 2) and fibrinolysis [plasminogen activator inhibitor (PAI) activity and concentrations of tissue plasminogen activator (tPA)/PAI-1 complexes] did not differ among the 3 diets. The mean platelet volume of the subjects decreased during consumption of the stearic acid diet by 0.32 fL compared with the oleic acid diet (P < 0.001) and by 0.35 fL compared with the linoleic acid diet (P < 0.001). In conclusion, our results do not suggest that stearic acid is highly thrombogenic compared with oleic and linoleic acids.

In the initial experience of liver transplantation, complete thrombosis and portal vein occlusion were considered to be absolute contraindications for liver transplantation. The incidence of portal thrombosis in patients being prepared for transplantation varies between 5% and 15% according to published series. There are 2 surgical techniques to solve absent or low portal vein flow due to thrombosis. The most widely used technique is thrombectomy and the second technique is insertion of a shunt with a venous graft in the permeable portion of the superior mesenteric vein or in a vein in the splanchnic territory. Portal thrombosis recurrence rates vary among series, ranging from 0% to 25% or even 30%, depending on its extension and severity and also on time the transplantation was performed. Although overall survival is somewhat lower, there are no significant differences in most of the series when patients with portal thrombosis who underwent transplantation are compared with those without.

Over 5 million central venous access devices (CVADs) are placed in the United States annually. Catheter occlusion is the most common non-infectious complication in long-term use of CVADs. Nursing management of the thrombotic occlusion of central venous access devices is described. The normal process of hemostasis and fibrinolysis and common types of catheter thrombosis are reviewed, along with the step-by-step procedure for restoring catheter patency using thrombolytic agents.

This study analyzes the data of thrombotic children who were followed up in different pediatric referral centers of Turkey, to obtain more general data on the diagnosis, risk factors, management, and outcome of thrombosis in Turkish children. A simple two-page questionnaire was distributed among contact people from each center to standardize data collection. Thirteen pediatric referral centers responded to the invitation and the total number of cases was 271. All children were diagnosed with thromboembolic disease between January 1995 and October 2001. Median age at time of first thrombotic event was 7.0 years. Of the children 4% of the cases were neonates, 12% were infants less than 1 year old, and 17% were adolescents. Thromboembolic event was mostly located in the cerebral vascular system (32%), deep venous system of the limbs, femoral and iliac veins (24%), portal veins (10%), and intracardiac region (9%). Acquired risk factors were present in 86% of the children. Infection was the most common underlying risk factor. Inherited risk factors were present in 30% of the children. FVL was the most common inherited risk factor. Acquired and inherited risk factors were present simultaneously in 19% of the patients. Eleven children had a history of familial thrombosis. Due to the local treatment preferences, the treatment of the children varied greatly. Outcome of the 142 patients (52%) was reported: 88 (62%) patients had complete resolution, 47 (33%) had complications, 12 (9%) had recurrent thrombosis, and 34 (24%) died. Three children (2.1%) died as a direct consequence of their thromboembolic disease. The significant morbidity and mortality found in this study supports the need for multicentric prospective clinical trials to obtain more generalizable data on management and outcome of thrombosis in Turkish children.

Background and Objectives: The purpose of this study was to assess the incidence of central venous catheter (CVC)-related thrombosis and the contribution of two common inherited coagulation disorders (factor V Leiden, prothrombin G20210A mutation) to this complication in a large hospital population., Design and Methods: In a prospective setting, patients were assessed daily for signs and symptoms suggestive of thrombosis. Routine Doppler-ultrasound was performed weekly in all patients until CVC removal. Doppler-ultrasound examinations were stored on videotape and assessed by two blinded observers. In the case of clinically suspected thrombosis the physicians followed routine diagnostic and therapeutic procedures. The presence of factor V Leiden and prothrombin G20210A mutation and other potential risk factors were assessed in all patients., Results: In 252 consecutive patients the cumulative incidence of-CVC related thrombosis was 30% (clinically manifested thrombosis: 7%). The relative risk of factor V Leiden or prothrombin G20210A mutation for thrombosis was 2.7 (CI95% 1.9 to 3.8). In addition, a personal history of venous thrombosis was associated with CVC-related thrombosis, whereas the severity of thrombosis was affected by the absence of anticoagulants and the presence of cancer., Interpretation and Conclusions: Thrombosis is frequently observed after central venous catheterization. Common inherited abnormalities in blood coagulation contribute substantially to CVC-related thrombosis. In view of physicians' reluctance to prescribe prophylactic anticoagulant treatment in vulnerable patients, a priori determination of common inherited and acquired risk factors may form a basis to guide these treatment decisions.

Purpose: To evaluate formalin-fixed blood-clot for diagnostic efficacy and safety in percutaneous CT-guided fine needle aspiration biopsy (FNAB) in addition to cytopathology., Materials and Methods: 61 CT-guided FNABs were entered into a prospective trial. FNAB was performed in 22 female and 39 male patients (32 - 83 years, m = 62.8 +/- 10.9 y) using 20- (n = 7) and 22-gauge (n = 54) needles. After correct placement within the tumor, material for cytopathological work-up was harvested. Additional material was sampled by needling (stirring and aspirating) within the lesion. These blood-clots were fixed in buffered formalin and delivered for histopathological work-up along with the smears. All results were correlated with the clinical course of the patient; cases of negative biopsies underwent surgery or were followed clinically for a minimum of 13 months (m = 14.8 +/- 1.4 months). Finally, all puncture-related side-effects and complications were analyzed and compared with data from 108 transthoracic FNABs performed over a two-year period before using this technique., Results: Tissue samples adequate for pathological diagnosis were obtained in 93.4 % (57 of 61 patients). Malignant cells were found in 50 samples, and 7 biopsy results were negative. The relevant pathological changes were depicted on both smear and blood-clot in 47 cases (82.4 %). In the remaining patients, the diagnoses were exclusively established by cytopathology (n = 6) and histopathology (n = 4). Altogether, additional information was obtained in 20 of the 57 FNABs (35.1 %). In the 47 cases with relevant findings obtained with both methods, the routine stain already led to the correct diagnosis in 9 cases by showing cohesive layers of malignant cells, and immunocytochemistry allowed subclassification of the biopsy material in additional 7 cases. Pneumothorax occurred in 12 of 38 transpleural punctures (31.6 %), hemoptysis in one patient (2.6 %). Four pneumothoraces required further treatment (3 thoracocenteses, 1 chest tube placement). Hemorrhagic complications requiring further treatment were not seen, but two minor hematomas were observed in the 19 abdominal punctures. The overall rate for pneumothorax was 38.9 % (42 of 108 interventions) for the FNAB performed in standard technique., Conclusion: Histological work-up of sampled blood-clots yielded a higher accuracy of CT-guided FNABs. Additional immunocytochemical studies allowed subclassification of tumor material. The complication rate of this technique was not higher than for FNAB alone.

Arterial hypercoagulability can lead to cerebrovascular disease. Common causes of venous thromboembolism, including factor V Leiden, the prothrombin 20210 mutation, deficiencies of proteins C and S, and antithrombin deficiency are not likely to be associated with stroke. Rather, polymorphisms in fibrinogen, the factor XIII gene, and platelet glycoproteins are congenital abnormalities that have been associated with stroke. Similarly, the acquired conditions, lupus anticoagulants, and heparin-induced thrombocytopenia have a strong association with cerebrovascular disease. This article reviews arterial hypercoagulability as a cause of stroke in adults and identifies an appropriate hypercoagulability workup for patients with idiopathic stroke.

It is very important to prevent embolisms from left atrial thrombi (LAT). The present study was a trial for the management of patients with AT using 122 patients with atrial fibrillation and LAT who were followed for 1 year after transesophageal echocardiography. LAT were classified by their shape and mobility into the mobile ball type (MB, n=28), fixed ball type (FB, n=32) and mountain type (MO, n=42). The patients were given warfarin (INR: 1.5-2.0, n=43), aspirin 81 mg (n=74) and/or ticlopidine 200 mg/day (n=31). The embolic rate (ER) in the MB group was significantly higher than in the other groups [ie, MB 39.3% vs FB 15.6% (p<0.05), vs MO 2.4% (p<0.05)]. The ER in the FB group was significantly higher than in the MO group (p<0.05). Therapy with a combination of ticlopidine and aspirin reduced the ER in the patients with ball thrombi. The ER of the ball thrombus type group, especially the MB group, was very high in spite of therapy with anti-coagulants and/or anti-platelet agents, and such patients should be treated by early surgical intervention. However, the combination of ticlopidine and aspirin may be useful for preventing embolism.

Although the common 4G/5G polymorphism in the promoter of the PAI-1 gene was suggested to be a risk factor for some of the thrombotic disorders, its significance in the development of thrombosis is still controversial. This study presents the data on a total of 357 patients with different types of thrombosis and 281 unrelated healthy controls. It was found that the 4G/4G genotype is associated with a higher risk of thrombosis (OR, 1.7; 95% CI, 1.1-2.5). Patients were divided into five distinct groups according to the site of thrombosis. Both 4G/4G and 4G/5G genotypes were associated with a higher risk of thrombosis development in a group of 69 patients with internal organ thrombosis (OR, 6.35; 95% CI, 2.5-16.1 and OR, 4.85; 95% CI, 2.0-12.1, respectively). Interestingly, this association was even stronger in a subgroup of 33 patients with portal vein thrombosis (PVT) and 4G/4G and 4G/5G genotypes conferred more than 10- and 6-fold increases in the risk of developing PVT (95% CI: 2.3-47.1 and 1.4-28.8), respectively. No statistically significant association was found between 4G/4G genotype and the groups of deep vein thrombosis (126 patients), cerebral thrombosis (80 patients), retinal thrombosis (72 patients), and purpura fulminans (16 patients). Factor V Leiden or prothrombin G20210A mutations did not emerge as additional risk factors for thrombosis in any of the groups studied. To conclude, this study suggests that there may be an association between 4G/4G and 4G/5G genotypes and the thrombosis in vessels of internal organs especially in the portal veins., (Copyright 2002 Wiley-Liss, Inc.)

Antiphospholipid antibodies are strongly associated with thrombosis and are the most common of the acquired blood protein defects causing thrombosis. Although the precise mechanism(s) whereby antiphospholipid antibodies alter hemostasis to induce a hypercoagutable state remain unclear, numerous theories, as previously discussed, have been advanced. The most common thrombotic events associated with anticardiolipin antibodies are deep vein thrombosis and pulmonary embolus (type I syndrome), coronary or peripheral artery thrombosis (type II syndrome), or cerebrovascular/retinal vessel thrombosis (type II syndrome); occasionally, patients present with mixtures of these types (type IV syndrome). Type V patients are those with antiphospholipid antibodies and RMS. It is as yet unclear how many seemingly normal individuals who may never develop manifestations of antiphospholipid syndrome (type VI) harbor asymptomatic antiphospholipid antibodies. The relative frequency of anticardiolipin antibodies in association with arterial and venous thrombosis strongly suggests that these should be looked for in any individual with unexplained thrombosis; all three idiotypes (IgG, IgA, and IgM) should be assessed. Also, the type of syndrome (I through VI) should be defined if possible, as this may dictate both type and duration of both immediate and long-term anticoagulant therapy. Unlike those with anticardiolipin antibodies, patients with primary lupus anticoagulant thrombosis syndrome usually experience venous thrombosis. Because the aPTT is unreliable inpatients with lupus anticoagulant (prolonged in only about 40 to 50% of patients) and is not usually prolonged in patients with anticardiolipin antibodies, definitive tests, including ELISA for anticardiolipin antibodies, the dRVVT for lupus anticoagulant, hexagonal phospholipid neutralization procedure, and beta-2-GP-I (IgG, IgA, and IgM) should be immediately ordered when suspecting antiphospholipid syndrome or in individuals with otherwise unexplained thrombotic or thromboembolic events. If results of these tests are negative, in the appropriate clinical setting, subgroups should also be assessed. Finally, most patients with antiphospholipid thrombosis syndrome will fail warfarin therapy and, except for retinal vascular thrombosis, may fail some types of antiplatelet therapy; thus it is of major importance to make this diagnosis so that patients can be treated with the most effective therapy for secondary prevention--LMWH or UH in most instances, and clopidogrel in some instances.

Heparin remains the most commonly used parenteral medication in hospitalized patients. Heparin induced thrombocytopenia (HIT) and heparin induced thrombocytopenia with thrombosis syndrome or the white clot syndrome are important complications of heparin use. This article provides an in-depth review of the etiopathogenesis, clinical manifestations, diagnosis, and management options in patients with HIT. Clinical problems associated with HIT such as antiphospholipid antibody syndrome and venous gangrene are described. The management options of HIT patients during cardiac interventional procedures and coronary surgery as well as recent advances in therapeutic options are summarized.

Erythromelalgia is a very specific, thrombotic syndrome related with thrombocythemia that may occur during the course of chronic myeloproliferative disorders (MPD), especially polycythemia vera (PV) and essential thrombocythemia (ET). This poorly understood clinical syndrome is characterized by red, congested distal extremities and painful burning sensations, usually confined to the ball of the foot and one or more toes or fingers. If left untreated, it may progress towards acrocyanosis and even peripheral gangrene. Sometimes, it may precede the diagnosis of MPD by months or years. The pathophysiological aspects of erythromelalgia as well as its differentiation with erythermalgia have been reviewed in this study.

The aim of this serial 3 year follow-up study in 42 clinically stable patients with chronic aortic dissection was to assess quantitatively morphologic changes of the descending thoracic aorta (AD) using transesophageal echocardiography (TEE). Communicating dissections (ca) were present in 16/19 patients with operated type I and in 11/23 patients with type III AD whereas 12/23 type III AD according to De Bakey were non-communicating (nc). Diametral enlargement of the disc. thoracic aorta was 4 mm (mean value) at 1 year in all patients, 5.9 mm in type I ca, 7.2 mm in type III ca but only 3.1 mm in type III nc at 3 years. The ratio between true lumen and false lumen (FL) changed in ca AD from 1:2 to 1:3 over the period of 3 years but remained constant at 1:1 in ncAD. Progressive thrombosis of the false lumen (FL) occurred in 76% of patients but complete thrombosis of the FL occurred in only 6% of type I ca, 18% type III ca but in 84% of type III nc patients. Our results confirm observations that non-communicating dissections seem to have a more favorable outcome and less aneurysmal dilatation compared to ca dissection.

Type-A right atrial thrombosis is characterized by echocardiographic detection of mobile worm-shaped thromboemboli in the right atrium, with a high propensity to embolic dislocation into the pulmonary circulation. This type of thrombus is associated with a very high mortality rate that exceeds 60% in untreated patients. Surgical embolectomy has been proposed as the treatment of choice, but the availability of an experienced surgical staff and the patients' eligibility for surgical treatment cannot be taken for granted. Efficacy of systemic thrombolysis for treatment of type-A right atrial thrombosis has repeatedly been reported during the past few years, with early mortality rates comparable to those of surgical approach. The major advantages of thrombolysis would be ease of administration and independence of patient's hemodynamic status. Our experience confirms these impressions and argues in favor of the routine use of systemic thrombolysis in the presence of a type-A right atrial thrombus, while reserving surgical embolectomy for patients with formal contraindications to thrombolysis.

Objective: To evaluate the incidence and risk factors for catheter-related central vein thrombosis in ICU patients., Design: Observational prospective multicenter study., Setting: An 8-bed surgical ICU, a 10-bed surgical cardiovascular ICU, and a 10-bed medical-surgical ICU., Patients: During an 18-month period, 265 internaljugular or subclavian catheters were included. Veins were explored by duplex scanning performed just before or < 24 h after catheter removal. Suspected risk factors of catheter-related central vein thrombosis were recorded., Interventions: None., Measurements and Main Results: Fifty-seven catheters were excluded from the analysis. Therefore 208 catheters were analyzed. Mean age of patients was 64+/-15 years, simplified acute physiologic score was 12+/-5, organ system failure score at insertion was 1+/-1, and mean duration of catheterization was 9+/-5 days. A catheter-related internal jugular or subclavian vein thrombosis occurred in 33% of the cases (42% [95% confidence interval (CI), 34 to 49%] and 10% [95% CI, 3 to 18%], respectively). Thrombosis was limited in 8%, large in 22%, and occlusive in 3% of the cases. Internal jugular route (relative risk [RR], 4.13; 95% CI, 1.72 to 9.95), therapeutic heparinization (RR 0.47; 95% CI, 0.23 to 0.99), and age >64 years (RR, 2.44; 95% CI, 2.05 to 3.19) were independently associated with catheter-related thrombosis. Moreover, the risk of catheter-related sepsis was 2.62-fold higher when thrombosis occurred (p=0.011)., Conclusions: Catheter-related central vein thrombosis is a frequent complication of central venous catheterization in ICU patients and is closely associated with catheter-related sepsis.

Objectives: To report on our experience in the treatment of renal cell carcinoma with vena caval or right atrial extension, with special reference to the level of involvement and the surgical technique indicated for each case., Methods: From early 1975 to April, 1997, 212 patients underwent surgery for renal cell carcinoma. Of these, 15 patients (11 male, 4 female), aged 27 to 73 years, had a tumor thrombus extending to the inferior vena cava. The tumor was located in the right kidney in 11 patients and in the left kidney in 4 patients. The tumor thrombus was infrahepatic in 10 cases, it extended beyond the suprahepatic veins in 3 cases, and 2 cases showed right atrial extension. The 10 patients with infrahepatic caval thrombus underwent radical nephrectomy with cavotomy and thrombus removal. In the remaining 5 patients with suprahepatic or atrial extension, thrombus removal was performed via cardiopulmonary by-pass with hypothermic circulatory arrest, with the assistance of a team of cardiac surgeons., Results: Pathological staging showed 2 T3cNoMo, 1 T3bNoMo and 2 T3bN1Mo in the patients who underwent cardiopulmonary bypass. There were 5 T3bNoMo, 2 T3bN2Mo, 1 T3bN2M1, 1 T4NoMo and 1 T4N1M1 in the group of patients with infrahepatic thrombus. There were two postoperative deaths. The overall survival rate was poor. Six patients are alive at 3-26 months' follow-up and 9 have died from disease progression. Patients with lymph node involvement or metastasis at the time of diagnosis had a worse survival rate., Conclusions: Surgical treatment of renal cancer with vena caval extension is specially difficult depending on the level of involvement, which must therefore be determined with precision. MRI is an effective and noninvasive technique. Tumors with thrombus below the suprahepatic veins can be managed by the direct approach with cavotomy. The use of cardiopulmonary bypass is advocated for tumors with suprahepatic caval or atrial extension. Tumors with caval-atrial extension have a negative influence on survival.

Objectives: Our aim was to determine whether tissue factor pathway inhibitor (TFPI), a physiologically important natural anticoagulant that acts by inhibiting the extrinsic pathway, concentrations decrease as liver disease progresses, and, second, whether TFPI has an etiologic role in portal vein thrombosis in cirrhotics., Methods: After taking their informed consent, we determined TFPI concentrations in the plasma of healthy subjects (group I) (n = 15) (average age, 45.1 = 11.8 yr), cirrhotics (group II) (n = 16) (average age, 43.6 +/- 9.8 yr), and cirrhotics with portal vein thrombosis (group III) (n = 12) (average age, 42.6 +/- 10.7 yr). Mean and median TFPI values and interquartile ratios were determined for groups I, II, and III. Then group II and III were further divided according to the Child classes A, B, or C, and mean and median TFPI values and interquartile ratios were determined for these classes as well. Using the Man-Whitney U test, we compared the results., Results: Statistically important differences were documented (p = 0.005) between the median TFPI levels of healthy adults and Child C cirrhotics (concentration lower in Child C) and between normal subjects and cirrhotics with portal vein thrombosis (p = 0.02) (TFPI concentration being lower in the latter group again)., Conclusions: TFPI concentration decreases in advanced liver disease, and this may be a contributory factor for portal vein thrombosis in at least some cases of cirrhotics.