Heparin-induced thrombocytopenia thrombosis after cardiac surgery. A case report

We report a rare case of cerebral infarct resulting in brain death due to heparin-induced thrombocytopenia thrombosis (HITT), manifested in the immediate postoperative period following aortic valve replacement in a 46-year-old woman whose only prior exposure to heparin was during catheterization four months prior to surgery. The diagnosis of HITT was suspected after a significant decrease of the platelet count and it was confirmed by a heparin-induced platelet activation assay showing platelet aggregation in the presence of heparin.     

The role of the vacuum-assisted closure therapy in the salvage of venous congestion of the free flap: case report

Indications for vacuum-assisted closure (VAC) therapy described generally include acute, chronic, traumatic wounds and ulcers. Recent studies related to investigating new applications of VAC therapy have begun to be reported at literature in many aspects. We used this technique in a novel area. A 21-year-old man presented who suffered venous congestion in anterolateral thigh fasciocutaneous flap at the postoperative second day. Following two cycles of VAC therapy, 72 hours later, venous congestion disappeared. Application of VAC therapy to the flap helps removal of excess interstitial fluid because of increased pressure gradients. It seems that VAC therapy is an option in venous congestion when the interstitial pressure rises above capillary pressure.     

Fondaparinux for intra and perioperative anticoagulation in patients with heparin-induced thrombocytopenia candidates for peripheral vascular surgery: Report of 4 cases

IntroductionIntra and perioperative anticoagulation in patients with heparin induced thrombocytopenia (HIT), candidates for peripheral vascular surgery remains a challenge, as the best alternative to heparin has not yet been established. We evaluated the off-label use of fondaparinux in four patients with HIT, undergoing peripheral vascular surgery procedures.Presentation of casesFour patients of whom 3 men of a mean age of 66 years, with proven heparin induced thrombocytopenia (HIT) underwent two axillo-femoral bypasses, one femoro-popliteal bypass and one resection of a splenic artery aneurysm under fondaparinux. No intra or perioperative bleeding or thrombosis of new onset was observed.DiscussionIn the absence of a valid alternative to heparin for intra and perioperative anticoagulation in HIT, several other anticoagulants can be used in an off-label setting. However, no general consensus exist on which should be the one of choice. In this small series fondaparinux appeared to be both safe and effective.ConclusionsThese preliminary results seem to justify the off-label use of fondaparinux for intra and perioperative anticoagulation in patients with HIT, candidates for peripheral vascular surgery interventions.     

肝素诱导性血小板减少症的诊断和治疗

肝素和低分子肝素可以引起免疫介导的药物不良反应—肝素诱导性血小板减少症,其临床表现十分危重甚至可以致命.对该病保持临床警觉可以及早发现,及早诊断,及早治疗.误诊或者对该病认知不足,可以导致患者出现严重并发症和死亡.本文就肝素诱导性血小板减少症的临床表现、诊断要点和治疗进行综述.     

阿加曲班联合置管溶栓治疗肝素诱导的血小板减少症及继发血栓

目的探讨阿加曲班抗凝联合阿替普酶溶栓治疗急性下肢深静脉血栓(DVT)合并肝素诱导血小板减少症(HIT)患者的临床疗效。方法回顾性分析6例急性DVT合并HIT患者的临床资料,均为使用肝素治疗DVT期间出现血小板减少合并血栓范围扩大,立即停用肝素,给予阿加曲班抗凝治疗,同时给予阿替普酶置管溶栓治疗。结果对6例HIT患者行阿加曲班联合阿替普酶溶栓综合介入治疗均有效,4例下肢肿胀完全消失,2例症状明显缓解。随访6~24个月,6例患者DVT均无复发。结论对于急性DVT接受肝素治疗后高度怀疑HIT者,应立即停用肝素,改用阿加曲班等替代抗凝药物,对于血栓范围扩大而尿激酶溶栓治疗无效者,可考虑改用阿替普酶溶栓治疗。     

Successful HeartMate 3 LVAD implantation in a patient with active heparin-induced thrombocytopaenia with thrombosis using pre-implantation plasmapheresis and intraoperative continuous prostacyclin

Heparin-induced thrombocytopaenia describes a prothrombotic state with significant rates of thrombus formation. We present a rare case of successful implantation of a HeartMate 3 left ventricular assist device in a patient with active heparin-induced thrombocytopaenia with thrombosis using preoperative plasmapheresis followed by intraoperative prostacyclin administration.     

低分子肝素联合间歇充气加压预防人工关节置换术后下肢深静脉血栓形成

目的比较在手术前后不同时间使用低分子肝素(low-molecular-weightheparin,LMWH)联合间歇充气加压装置(intermittentpneumaticcompression,IPC)预防人工关节置换术后下肢深静脉血栓(deepvenousthrombosis,DVT)形成的效果和安全性。方法2003年7月至2005年6月,156例人工关节置换手术病例,随机分成4组。第1组38例,术前使用LMWH、麻醉开始时即使用IPC;第2组42例,术后使用LMWH、麻醉开始时即使用IPC;第3组36例,术前使用LMWH、术后使用IPC;第4组40例,术后使用LMWH与IPC。进行DVT症状评估、下肢深静脉的彩超检查,观察出血并发症与记录围手术期出血量。结果第1组,DVT2例(5.26%),出血量(1030.8±282.0)ml;第2组,DVT2例(4.76%),出血量(900.7±246.9)ml;第3组,DVT1例(2.78%),出血量(1040.3±288.5)ml,1例上消化道出血;第4组,DVT9例(22.5%),出血量(852.2±295.4)ml。在DVT发生率上,第1、2、3组明显低于第4组(P﹤0.05);在围手术期出血量上,第2、4组少于第1、3组(P﹤0.05)。结论术后使用LMWH联合麻醉开始时即使用IPC以预防人工关节置换术后DVT发生的效果好,安全性高。     

The free lateral arm flap in reconstructive hand surgery

Microsurgical tissue transplantation has provided a great advance in reconstructive surgery, especially regarding upper limb defects. Compared to conventional pedicled flaps, mobilisation can occur earlier, hospital stay is shorter and no additional interventions for pedicle detachment and flap inset are needed. The lateral arm flap is an exceptionally versatile free flap with straightforward dissection and low donor site morbidity. End-to-side anastomosis preserves blood flow through the main arteries to the hand and reduces the risk of vascular compromise of the hand, which is especially important in case of severe hand injuries. Sixteen patients who underwent hand reconstruction using the lateral arm free flap are reviewed. All arterial anastomoses were conducted in end-to-side-technique either to the radial or the ulnar artery. There was no total- or partial-flap failure and only one revisional procedure due to a haematoma under the anastomosis. Eight flaps required secondary defatting, combined with removal of osteosynthesis material or tenolysis. From our point of view the free lateral arm flap is a very reliable and versatile method to resurface small and medium sized hand defects.     

高龄人工髋关节置换术后下肢深静脉血栓形成药物预防的比较研究

目的：比较利伐沙班与低分子肝素钠两种药物对于预防人工髋关节置换术后下肢深静脉血栓形成的临床疗效和安全性。方法对本院行人工髋关节置换手术的病例98例进行分析,评价双下肢彩色多普勒检查评估DVT形成情况,比较 PT、APTT、PLT指标,并进行统计学分析。结果利伐沙班组与低分子肝素钠组在预防DVT形成疗效上无显著性差异（P＞0.05）,两组在术后治疗期间均无严重出血, PT、APTT、PLT比较无显著性差异（P＞0.05）。结论利伐沙班与低分子肝素钠在预防人工髋关节置换术后 DVT的疗效与安全性上效果相近,利伐沙班服用方便,更易被患者接受。     

Unusual case of a free anterolateral thigh flap partial necrosis in a COVID-19 positive young male following extremity reconstruction

Free flap procedure provides an overall success rate of 97%, which decreases to 85% in hypercoagulable states. COVID-19, as a pro-thrombotic disorder, therefore seems detrimental to free flap survival. We encountered a case of unique pattern of free flap partial failure in a young male who underwent extremity reconstruction. The patient was diagnosed as COVID-19 positive on the 3rd day post-reconstruction. The flap survived well for the first 7 days post-operatively, but gradually the skin got necrosed and the subcutaneous fat layer was preserved when debriding. To our knowledge, this is the only case in which the skin of the free flap of a COVID-19 positive patient was necrosed almost entirely subsequently, while the subcutaneous fat was relatively preserved.     

髋膝关节置换围手术期下肢深静脉血栓形成与 D-二聚体及抗凝药的关系

目的：探索髋膝关节置换围手术期下肢深静脉血栓形成与 D-二聚体升高关系及使用不同抗凝药的有效性和安全性评估。方法前瞻性分析70例行髋膝关节置换的患者,根据术后双下肢彩色多普勒超声结果,分为血栓组（11例）和非血栓组（59例）,记录两组在术前及术后D-二聚体浓度并进行统计分析。同时按照使用抗凝药不同分为低分子肝素（速碧林）预防组和利伐沙班预防组,记录并比较二者DVT发生率和术后伤口引流量关系。结果血栓组术前D-二聚体浓度与非血栓组术前D-二聚体的浓度相比较有显著性差异（P＜0.01）,血栓组较非血栓组增高。血栓组与非血栓组术后第7天的D-二聚体浓度比较则无显著性差异（P＞0.05）,血栓组与非血栓组各自组内比较,术后与术前的D-二聚体浓度比较均有显著性差异（P＜0.01）,术后浓度较术前均有增高。在使用抗凝药物情况下DVT的发病率为15.71％,利伐沙班与低分子肝素（速碧林）干预后DVT发生的情况无显著性差异（ P＞0.05）。术后伤口引流量无统计学差异（ P＞0.05）。结论研究发现D-二聚体对DVT预测不是特异性指标;髋膝关节置换术后使用抗凝药物情况下 DVT发生情况明显下降,利伐沙班与低分子肝素对于预防DVT作用上无显著性差异。     

游离皮瓣移植在整形外科的临床应用

目的 回顾总结游离皮瓣在整形外科应用的范围与经验,方法 收集近８年来临床应用游离皮瓣的病例５０例进行统计分析。结果 ５０例中有４７例用于早晚期严重创伤伴有深部组织缺损与外露者,另３例为肿瘤切除后的创面覆盖,成功且效果良好者４８例（９６％）有２例由于血清栓塞而失败,结论 游离皮瓣的应用提高了整形外科的救治水平,对某些疑难病例的治疗是其它方法不可替代的。     

腹腔镜术后下肢静脉血栓形成分析

目的：探讨腹腔镜术后下肢静脉血栓发生的原因和预防措施。方法：回顾分析2000年5月至2006年5月2 000余例各种腹腔镜术后出现的26例下肢静脉血栓患者的临床资料。结果：手术时间20-200min,15例下肢浅静脉血栓治疗5-7d后症状消失,复查彩色多普勒血栓消失,随访3-12个月无复发。11例髂—股及股深静脉、血栓,经抗凝治疗14-21d症状消失,随访12个月无复发。结论：腹腔镜术后下肢静脉血栓的发生与患者高危因素、CO2气腹、体位等密切相关,在围手术期应积极采取措施予以预防。     

指背旗形静脉皮瓣的设计与应用

目的根据指背静脉及静脉弓的解剖特点,改进旗形皮瓣的设计与应用。方法利用桡侧或尺侧指背静脉为轴心静脉,用逆行设计法,为6例指掌侧与手掌侧相联的缺损设计了旗形静脉皮瓣修复。结果全部成活,伤口Ⅰ期愈合。随访3个月,手指活动及外形良好。结论此类皮瓣可Ⅰ期同时修复指掌侧和手掌侧皮肤缺损,扩大了旗形皮瓣的应用范围。     

静脉血栓形成的分子影像学

静脉血栓形成是一种临床急重症,早期诊断、判断血栓形成的时期、识别血栓成分具有重要临床意义。分子影像学可以在分子水平对血栓进行显示与诊断,主要成像靶点有纤维蛋白、血小板、活化的因子ⅩⅢ、凝血酶、P选择素等。