Occlusion of the Modified Blalock–Taussig Shunt: Unique Methods of Treatment and Review of Catheter‐based Intervention

Objective. To report unique methods of treatment and review catheter‐based intervention for occluded modified Blalock–Taussig shunts (BTS). Methods. Case reports and articles involving children undergoing catheter‐based treatment for occluded modified BTS were reviewed. Results. Literature review detailed 38 patients in whom occluded modified BTS were treated with 39 catheter‐based interventions. Thrombolytics alone were delivered by catheter in 13 cases. Balloon angioplasty was performed in 23 cases, 5 with stent implantation. Both thrombolytic delivery and angioplasty were performed in 3 cases, 2 with stent implantation. Intervention was initially successful at re‐establishing modified BTS patency in 35/39 (90%) of cases. Patency could not be established in 2 patients who then proceeded to the operating for surgical shunt revision. Two deaths occurred during the procedures. Three cases at Emory University demonstrate uncommon or unique instances of catheter‐based intervention: (1) declotting of a shunt in a patient supported by extracorporeal membrane oxygenation (ECMO); (2) declotting of a shunt via a right axillary arterial approach; and (3) declotting of a shunt using a carotid arterial (ECMO) cannula for percutaneous access. Conclusions. The use of catheter‐based techniques for the treatment of BTS occlusion is highly successful, and potentially avoids high‐risk re‐operative intervention. ECMO can provide for a stable patient during the procedure. Hopefully, with improved technology and innovative procedures, more children in the future with BTS occlusion can be served by successful percutaneous intervention.     

脑动脉粥样硬化和脑血栓者血浆D－二聚体检测及临床意义

检测３２例脑动脉粥样硬化和２８例脑血栓病人血浆Ｄ－二聚体含量，并与３３例年龄匹配的健康人（对照组）比较。结果Ｄ－二聚体含量在对照组为０．４３±０．２６ｍｇ／Ｌ；脑动脉粥样硬化组与脑血栓形成组（病后＜７ｄ、４ｗ、６ｗ３个时期）血浆Ｄ－二聚体含量分别为０．８６±０．４８、１．０２±０．９７、１．０７±１．０４和１．０５±０．８７ｍｇ／Ｌ，与对照组相比均明显升高（Ｐ均＜０．００１），但脑动脉粥样硬化和脑血栓形成两组之间无显著差异（Ｐ＞０．０５）。认为Ｄ－二聚体可作为检测血栓前状态和病情判断的指标。     

Evaluation of thrombotic children with malignancy

The purpose of this study was to evaluate inherited and acquired prothrombotic risk factors among children with malignancies who have thrombosis and emphasize the importance of inherited prothrombotic risk factors. Thirty-seven consecutive children with thrombosis and malignancy were included in this study. The patients were evaluated separately for time of development of thrombosis, insertion of a central venous line (CVL), history of l-asparaginase usage, and recent infections. Prothrombotic risk factors such as factor V G1691A and prothrombin G20210A mutation, protein C, protein S, antithrombin III deficiencies, factor VIII and lipoprotein(a) elevation, and antiphospholipid antibodies were analyzed for all patients. Of 387 children with thrombosis, 37 (9.5%) had a malignancy. Thrombosis was detected in 9 patients at the time of diagnosis, during maintenance therapy in 25 patients, and after the discontinuation of treatment in 3 patients. One or two additional prothrombotic risk factors other than l-asparaginase therapy and insertion of central venous lines were present in 20 of these patients (54%). It was found that eight patients had the factor V G1691A mutation in the heterozygote state. One of them had the factor V G1691A mutation associated with a history of infection and one patient had the factor V G1691A mutation associated with factor VIII elevation. One had the the prothrombin G20210A mutation in the heterozygote state, four had lipoprotein(a) elevation, two had factor VIII elevation, one had a decreased protein S level, one had a decreased protein C level, one had antiphospholipid positivity, and two had histories of infection. Malignancy is an important risk factor for the development of childhood thrombosis. However, the risk of thrombosis increases when accompanied by additional prothrombotic risk factors. For this reason, especially children with malignancy and at high risk for the development of thrombosis, such as those who have received l-asparaginase or a replaced CVL during their therapy, might be screened for additional prothrombotic risk factors and appropriate measures might be taken to prevent the development of thrombosis.     

Hyperhomocysteinaemia and Risk of Thrombosis in Systemic Lupus Erythematosus Patients

Hyperhomocysteinaemia is strongly associated with increased relative risk of occlusive vascular disease, mainly of the carotid and coronary arteries. The aim of our study was to assess whether raised plasma homocysteine is a risk factor for thrombotic events in patients with systemic lupus erythematosus (SLE), a condition known to be associated with premature atherothrombotic complications. The study included 34 consecutive consenting SLE patients who were seen in the Rheumatology Unit of Al-Amiri hospital, one of the main teaching hospitals in Kuwait. Twenty consenting healthy subjects were included in the control group. Twenty-four patients were grouped as SLE without thrombosis and 10 had different types of thromboses. Vitamin B₁₂, folate, anticardiolipin antibodies (IgG and IgM), activated partial thromboplastin time (APTT) and total homocysteine level were measured for both patients and controls. A raised homocysteine concentration was defined as plasma homocysteine level above 9.4 mmol/l. Hyperhomocysteinaemia was found in 21 (61.8%) SLE patients. Low levels of folate and vitamin B₁₂ were significantly associated with high concentrations of plasma homocysteine (r = −0.35 and −0.39, respectively, P<0.01). SLE patients with elevated homocysteine concentration have a threefold increase in odds ratio of thrombotic events after adjusting for other risk factors (male sex, shortened APTT, treatment with prednisone, low folate and vitamin B₁₂ levels). We concluded that homocysteine is an independent risk factor for thrombosis in patients with SLE and is potentially modifiable. Received: 27 December 2001 / Accepted: 14 April 2002 Correspondence and offprint requests to: Dr I. H. Al-Salem, PO Box 16434, Al-Qadeseyah 35855, Kuwait. Tel: 965 2532025; Fax: 965 2666205; E-mail: driqbalham@hotmail.com     

妇科手术患者并发血栓的危险因素分析及护理干预措施

目的探讨妇科手术患者并发血栓的危险因素及护理干预措施。方法选取2018年1月至2019年12月在我院妇科住院的手术患者1623例,根据患者的临床资料分析发生血栓并发症的危险因素,并制定针对性预防护理措施。结果1623例妇科手术患者中发生血栓并发症184例,发生血栓和未发生血栓的患者年龄、BMI、文化程度、合并基础疾病、凝血功能异常、术后卧床时间、饮水情况比较,差异有统计学意义(P<0.05);Logistic回归分析结果显示,患者年龄、BMI、合并基础疾病、凝血功能异常、患者术后卧床时间、饮水情况均为手术患者发生血栓的独立危险因素。结论妇科手术患者并发血栓的相关危险因素较多,护理人员应加强对患者的高风险评估、筛查及预防性护理的健康宣教及督导落实,重视家庭成员的共同干预,尽量降低血栓发生的风险及相关并发症,提高患者的安全及生活质量。     

The incidence of deep vein thrombosis and pulmonary embolism with the elective use of external fixators

Little evidence exists about the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) with the use of external fixators. We investigated this in a cohort of 207 consecutive patients undergoing 258 elective frame applications by case note review. Case notes were obtained for 84 % of the sample population. The type of surgery, demographic data, thromboembolic risk factors and the incidence of DVT/PE were recorded. One patient experienced DVT (0.39 %) and one a PE (0.39 %). Both were of high risk and had received mechanical and chemical thromboprophylaxis during their inpatient stay. These complications were identified at least 3 months post-operatively. These findings help to more accurately counsel patients undergoing elective frame surgery on the risks of DVT/PE and also contribute to the discussion between surgeons about whether or not extended course chemical thromboprophylaxis would be of overall benefit.     

Acute celiac trunk thrombosis revealed by biliary peritonitis

Acute thrombosis of the celiac trunk is a very uncommon condition, which is a life-threatening emergency. The clinical presentation is highly variable depending on the extent of the ischemic territory. We report a case of biliary peritonitis related to an acute thrombosis of the celiac trunk. This case highlights the role of abdominal computed tomography in the diagnosis of acute upper abdominal pain.     

Safety and Efficacy of Low Dosage of Urokinase for Catheter-directed Thrombolysis of Deep Venous Thrombosis

Background:

Catheter-directed thrombolysis (CDT) has been a mainstay in treating deep venous thrombosis (DVT). However, the optimal dosage of a thrombolytic agent is still controversial. The goal of this study was to evaluate the safety and efficacy of low dosage urokinase with CDT for DVT.

Methods:

A retrospective analysis was performed using data from a total of 427 patients with DVT treated with CDT in our single center between July 2009 and December 2012. Early efficacy of thrombolysis was assessed with a thrombus score based on daily venography. The therapeutic safety was evaluated by adverse events. A venography or duplex ultrasound was performed to assess the outcome at 6 months, 1 year and 2 years postoperatively.

Results:

The mean total dose of 3.34 (standard deviation [SD] 1.38) million units of urokinase was administered during a mean of 5.18 (SD 2.28) days. Prior to discharge, Grade III (complete lysis) was achieved in 154 (36%) patients; Grade II (50–99% lysis) in 222 (52%); and Grade I (50% lysis) in 51 (12%). The major complications included one intracranial hemorrhage, one hematochezia, five gross hematuria, and one pulmonary embolism. Moreover, no death occurred in the study.

Conclusions:

Treatment of low-dose catheter-directed thrombosis is an efficacious and safe therapeutic approach in patients with DVT offering good long-term outcomes and minimal complications.     

Stent thrombosis following bare-metal stent implantation: success of emergency percutaneous coronary intervention and predictors of adverse outcome.

AIMS: To investigate the efficacy and outcome of emergency percutaneous coronary interventions (PCI) in patients with stent thrombosis. METHODS AND RESULTS: Between 1995 and 2003, 6058 patients underwent bare-metal stent implantation, of which 95 (1.6%) patients suffered from stent thrombosis. The timing of stent thrombosis was acute in 10 (11%), subacute in 61 (64%), and late in 24 (25%) patients. Procedural and clinical outcomes of emergency PCI for treatment of stent thrombosis were investigated. Emergency PCI was successful in 86 (91%), complicated by death in 2 (2%), and coronary artery bypass grafting in 2 (2%) patients. Myocardial infarction occurred in 77 (81%) patients with a peak creatine kinase level of 1466+/-1570 U/L. Left ventricular ejection fraction declined from 0.54+/-0.19 prior to 0.48+/-0.16 (P<0.05) at the time of stent thrombosis after emergency PCI. A 6 month major adverse clinical events comprised death (11%), reinfarction (16%), and recurrent stent thrombosis (12%) after emergency PCI. Multivariable logistic regression analysis identified the achievement of TIMI 3 flow (OR=0.1, CI 95% 0.01-0.54, P<0.001) and diameter stenosis <50% (OR=0.06, CI 95% 0.01-0.32, P<0.001) during emergency PCI to be independently associated with a reduced risk of cardiac death. Recurrent stent thrombosis was independently predicted by the omission of abciximab (OR=4.3, CI 95% 1.1-17.5). CONCLUSION: Emergency PCI for treatment of stent thrombosis effectively restores vessel patency and flow. Patients presenting with stent thrombosis are at risk for recurrent myocardial infarction and recurrent stent thrombosis.