Transcatheter aortic valve implantation (TAVI) has emerged as a therapeutic alternative for patients with symptomatic aortic stenosis at high or prohibitive surgical risk. However, patients ...undergoing TAVI are also at high risk for both bleeding and stroke complications, and specific mechanical aspects of the procedure itself can increase the risk of these complications. The mechanisms of periprocedural bleeding complications seem to relate mainly to vascular/access site complications (related to the use of large catheters in a very old and frail elderly population), whereas the pathophysiology of cerebrovascular events remains largely unknown. Further, although mechanical complications, especially the interaction between the valve prosthesis and the native aortic valve, may play a major role in events that occur during TAVI, post-procedural events might also be related to a prothrombotic environment or state generated by the implanted valve, the occurrence of atrial arrhythmias, and associated comorbidities. Antithrombotic therapy in the setting of TAVI has been empirically determined, and unfractionated heparin during the procedure followed by dual antiplatelet therapy with aspirin (indefinitely) and clopidogrel (1 to 6 months) is the most commonly recommended treatment. However, bleeding and cerebrovascular events are common; these may be modifiable with optimization of periprocedural and post-procedural pharmacology. Further, as the field of antiplatelet and anticoagulant therapy evolves, potential drug combinations will multiply, introducing variability in treatment. Randomized trials are the best path forward to determine the balance between the efficacy and risks of antithrombotic treatment in this high risk-population.
Antithrombotic use is a significant risk factor of postpolypectomy bleeding (PPB). Evidence of prophylactic clipping is only available for proximal and large colonic lesions in the general ...population. Dedicated studies to examine the benefit of prophylactic clipping in patients on aspirin remain scarce.
A propensity score–weighted retrospective cohort study was performed in a tertiary referral center from January 2018 to September 2021. Patients who received aspirin and underwent colonoscopic polypectomy, EMR, or endoscopic submucosal dissection were included. Data on baseline demographics, medications, and endoscopic factors (polyp number, size, location, and morphology; resection method; and prophylactic clipping) were captured. Propensity score–weighted models were developed between prophylactic clipping and no clipping groups. The primary outcome was delayed PPB within 30 days, with a composite endpoint consisting of repeated colonoscopy for hemostasis, requirement of blood transfusion, or hemoglobin drop >2 g/dL.
A total of 1373 patients with 3952 polyps were included. Baseline characteristics were balanced between the 2 groups. In the multivariate analysis, the largest polyp size was a significant risk factor for PPB (odds ratio, 1.07; 95% confidence interval, 1.02-1.11; P = .002). Prophylactic clipping was not associated with a reduced risk of PPB (odds ratio, 1.34; 95% confidence interval, .83-2.18; P = .240) and did not show any risk reduction in subgroups with different polyp sizes and locations and endoscopic resection techniques.
Prophylactic clipping was not associated with a lower risk of PPB in aspirin users after endoscopic resection of colorectal polyps. Aspirin use should not be regarded as the only factor for the routine use of prophylactic clips.
Introduction
This review assesses the presentation, management, and outcome of delayed postpancreatectomy hemorrhage (PPH) and suggests a novel algorithm as possible standard of care.
Methods
An ...electronic search of Medline and Embase databases from January 1990 to February 2010 was undertaken. A random-effect meta-analysis for success rate and mortality of laparotomy vs. interventional radiology after delayed PPH was performed.
Results
Fifteen studies comprising of 248 patients with delayed PPH were included. Its incidence was of 3.3%. A sentinel bleed heralding a delayed PPH was observed in 45% of cases. Pancreatic leaks or intraabdominal abscesses were found in 62%. Interventional radiology was attempted in 41%, and laparotomy was undertaken in 49%. On meta-analysis comparing laparotomy vs. interventional radiology, no significant difference could be found in terms of complete hemostasis (76% vs. 80%;
P
= 0.35). A statistically significant difference favored interventional radiology vs. laparotomy in term of mortality (22% vs. 47%;
P
= 0.02).
Conclusions
Proper management of postoperative complications, such as pancreatic leak and intraabdominal abscess, minimizes the risk of delayed PPH. Sentinel bleeding needs to be thoroughly investigated. If a pseudoaneurysm is detected, it has to be treated by interventional angiography, in order to prevent a further delayed PPH. Early angiography and embolization or stenting is safe and should be the procedure of choice. Surgery remains a therapeutic option if no interventional radiology is available, or patients cannot be resuscitated for an interventional treatment.
Postoperative bleeding complications surveillance is done primarily through manual chart review. The purpose of this study was to develop and validate a detection model for postoperative bleeding ...complications using structured electronic health records data.
Patients who underwent operations at 1 of 5 hospitals within our local health system between 2013 and 2019 and whose complications were reported by the American College of Surgeons National Surgical Quality Improvement Program were included. Electronic health records data were linked to American College of Surgeons National Surgical Quality Improvement Program data using personal health identifiers. Electronic health records predictors included diagnosis codes mapped to PheCodes, procedure names, and medications within 30 days after surgery. We defined bleeding events as the transfusion of red blood cell components within 30 days after surgery. The knockoff filter and the lasso were used to develop a model in a training set of operations from January 2013 to March 2017. Performance of each model was tested in a held-out data set of patients who underwent operations from March 2017 to October 2019.
A total of 30,639 patients were included; 1,112 patients (3.6%) had a bleeding event. Eight predictor variables were selected by the knockoff filter. When applied to the test set, specificity was 94%, sensitivity was 94%, area under the curve was 0.97, and accuracy was 93%. Calibration was consistent in lower predicted risk patients, whereas the model slightly overpredicted risk in high-risk patients.
We created a parsimonious, accurate model for identifying patients with bleeding complications. This model can be used to augment manual chart review for surveillance and reporting of perioperative bleeding complications, enabling inclusion of all surgeries in quality improvement efforts.
Detrimental consequences of hypofibrinolysis, also known as fibrinolysis shutdown (FS), have recently arisen, and its significance in liver transplantation (LT) remains unknown. To fill this gap, ...this retrospective study included 166 adults who received transplants between 2016 and 2018 for whom baseline thromboelastography was available. On the basis of percent of clot lysis 30 minutes after maximal amplitude, patients were stratified into 3 fibrinolysis phenotypes: FS, physiologic fibrinolysis, and hyperfibrinolysis. FS occurred in 71.7% of recipients, followed by physiologic fibrinolysis in 19.9% and hyperfibrinolysis in 8.4%. Intraoperative and postoperative venous thrombosis events occurred exclusively in recipients with the FS phenotype. Intraoperative thrombosis occurred with an overall incidence of 4.8% and was associated with 25.0% in‐hospital mortality. Incidence of postoperative venous thrombosis within the first month was deep venous thrombosis/pulmonary embolism (PE; 4.8%) and portal vein thrombosis/hepatic vein thrombosis (1.8%). Massive transfusion of ≥20 units packed red blood cells was required in 11.8% of recipients with FS compared with none in the other 2 phenotype groups (P = 0.01). Multivariate analysis identified 2 pretransplant risk factors for FS: platelet count and nonalcoholic steatohepatitis/cryptogenic cirrhosis. Recursive partitioning identified a critical platelet cutoff value of 50 × 109/L to be associated with FS phenotype. The hyperfibrinolysis phenotype was associated with the lowest 1‐year survival (85.7%), followed by FS (95.0%) and physiologic fibrinolysis (97.0%). Infection/multisystem organ failure was the predominant cause of death; in the FS group, 1 patient died of exsanguination, and 1 patient died of massive intraoperative PE. In conclusion, there is a strong association between FS and thrombohemorrhagic complications and poorer outcomes after LT.
Purpose
The influence of tonsil anatomical differences on post-tonsillectomy hemorrhage and pain has not been studied yet. This study aimed to establish a classification and grading scale of palatine ...tonsil anatomy, not size, for personalized post-tonsillectomy care.
Methods
Between August 2020 and August 2021, 337 children who underwent extracapsular tonsillectomy were recruited. The images of tonsil anatomy during the surgery were recorded and then classified and graded. Postoperative hemorrhage was recorded, and the degree of pain was measured using a visual analog scale (VAS). The primary outcomes were the associations between postoperative hemorrhage, pain, and the classification and grade of tonsil anatomy, analyzed by univariable and multivariable analyses.
Results
186 of the 337 patients (55.2%) were male and 151 (44.8%) were female; the mean age was 5.59 years. The overall postoperative hemorrhage rate was 4.1%. The mean postoperative VAS score was 4.96. By univariable analysis with logistic regression model, significant associations were found between postoperative hemorrhage and the grade 2 and grade 3 tonsillar lower pole, and grade 3 tonsillar bed. Multivariable analysis with binary logistic regression model also revealed significant associations between postoperative hemorrhage and the grade 2 and grade 3 lower pole (OR: 8.23, 95% CI 1.01–67.37,
P
= 0.049; OR: 23.86, 95% CI 2.22–56.47,
P
= 0.009, respectively) and grade 3 tonsillar bed (OR: 14.25, 95% CI 1.46–18.75,
P
= 0.022). Linear regression analysis showed the associations between postoperative pain and grade 2 and grade 3 lower pole (
β
: 0.88, 95% CI 0.31–1.32,
P
= 0.002;
β
: 1.56, 95% CI 1.29–3.29,
P
= 0.001, respectively) and grade 3 anterior surface (
β
: 0.85, 95% CI 0.30–3.07,
P
= 0.004). Age and upper pole were not associated with the postoperative hemorrhage and pain neither.
Conclusion
In the present study, we established a novel classification and 3-grade scale of palatine tonsil anatomy, based on upper pole, anterior surface, lower pole, and tonsillar bed. Furthermore, we revealed for the first time that some anatomical characteristics of tonsils were associated with post-tonsillectomy complications.
Purpose
To analyze the risk of postoperative hemorrhage in tonsil surgery with different surgical methods, instruments, indications, and age groups. Monopolar diathermy compared to bipolar diathermy ...was of particular interest.
Methods
The data from tonsil surgery patients were retrospectively collected between 2012 and 2018 in the Hospital District of Southwest Finland. The surgical method, instruments, indication, sex and age and their association with a postoperative hemorrhage were analyzed.
Results
A total of 4434 patients were included. The postoperative hemorrhage rate for tonsillectomy was 6.3% and for tonsillotomy 2.2%. The most frequently used surgical instruments were monopolar diathermy (58.4%) cold steel with hot hemostasis (25.1%) and bipolar diathermy (6.4%) with the overall postoperative hemorrhage rates 6.1%, 5.9% and 8.1%, respectively. In tonsillectomy patients, the risk for a secondary hemorrhage was higher with bipolar diathermy compared to both monopolar diathermy (p = 0.039) and the cold steel with hot hemostasis technique (p = 0.029). However, between the monopolar and the cold steel with hot hemostasis groups, the difference was statistically non-significant (p = 0.646). Patients aged > 15 years had 2.6 times higher risk for postoperative hemorrhage. The risk of a secondary hemorrhage increased with tonsillitis as the indication, primary hemorrhage, tonsillectomy or tonsillotomy without adenoidectomy, and male sex in patients aged ≤ 15 years.
Conclusion
Bipolar diathermy increased the risk for secondary bleedings compared to both monopolar diathermy and the cold steel with hot hemostasis technique in tonsillectomy patients. Monopolar diathermy did not significantly differ from the cold steel with hot hemostasis group regarding the bleeding rates.
Background
The antifibrinolytic tranexamic acid reduces surgical blood loss, but studies have not identified an optimal regimen.
Questions/purposes
We studied different dosages, timings, and modes of ...administration to identify the most effective regimen of tranexamic acid in achieving maximum reduction of blood loss in TKA.
Methods
We prospectively studied five regimens (four intravenous, one local; 40 patients each) with a control group (no tranexamic acid). The four intravenous (10-mg/kg dose) regimens included (1) intraoperative dose (IO) given before tourniquet deflation, (2) additional preoperative dose (POIO), (3) additional postoperative dose (IOPO), and (4) all three doses (POIOPO). The fifth regimen was a single local application (LA). Two independent parameters of drain loss and total blood loss, calculated by the hemoglobin balance method, were evaluated statistically.
Results
Both parameters were reduced in all five regimens as against the control. A significant reduction in drain loss was seen in the POIO, IOPO, and POIOPO groups whereas total blood loss was significantly reduced in the POIO, POIOPO, and LA groups. The POIOPO group had the least drain loss (303 mL) and least total blood loss (688 mL). The IO group had the greatest drain loss and the IOPO group the greatest total blood loss.
Conclusions
Single-dose tranexamic acid did not give effective results. The two-dose regimen of POIO was the least amount necessary for effective results. When compared against the control, this regimen produced reduction of drain loss and total blood loss, whereas the IOPO regimen did not. The three-dose regimen of POIOPO produced maximum effective reduction of drain loss and total blood loss.
Level of Evidence
Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Background
There is considerable debate regarding the ideal agent for venous thromboembolism (VTE) prophylaxis after TKA. Numerous studies and meta-analyses have yet to provide a clear answer and ...often omit one or more of the commonly used agents such as aspirin, warfarin, enoxaparin, and factor Xa inhibitors.
Questions/Purposes
Using a large database analysis, we asked: (1) What are the differences in VTE incidence in primary TKA after administration of aspirin, warfarin, enoxaparin, or factor Xa inhibitors? (2) What are the differences in bleeding risk among these four agents? (3) How has use of these agents changed with time?
Methods
We queried a combined Humana and Medicare database between 2007 and Quarter 1 of 2016, and identified all primary TKAs performed using ICD-9 and Current Procedural Terminology codes. All patients who had any form of antiplatelet or anticoagulation prescribed within 1 year before TKA were excluded from our study cohort. We then identified patients who had either aspirin, warfarin, enoxaparin, or factor Xa inhibitors prescribed within 2 weeks of primary TKA. Each cohort was matched by age and sex. Elixhauser comorbidities and Charlson Comorbidity Index for each group were calculated. We identified 1016 patients with aspirin, and age- and sex-matched 6096 patients with enoxaparin, 6096 patients with warfarin, and 5080 patients with factor Xa inhibitors. Using ICD-9 codes, with the understanding that patients at greater risk may have had more-attentive surveillance, the incidence of postoperative deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding-related complications (bleeding requiring surgical intervention, hemorrhage, hematoma, hemarthrosis), postoperative anemia, and transfusion were identified at 2 weeks, 30 days, 6 weeks, and 90 days postoperatively. A four-way chi-squared test was used to determine statistical significance. Utilization was calculated using compound annual growth rate.
Results
There was a difference in the incidence of DVT at 90 days (p < 0.01). Factor Xa inhibitors (2.9%) had the lowest incidence of DVT followed by aspirin (3.0%) and enoxaparin (3.5%), and warfarin (4.8%). There was a difference in the incidence of PE at 90 days (p < 0.01). Factor Xa inhibitors (0.9%) had the lowest incidence of PE followed by enoxaparin (1.1%), aspirin (1.2%), and warfarin (1.6%). There was a difference in the incidence of postoperative anemia at 90 days (p < 0.01). Aspirin (19%) had the lowest incidence of postoperative anemia followed by warfarin (22%), enoxaparin (23%), and factor Xa inhibitors (23%). There was a difference in the incidence of a blood transfusion at 90 days (p < 0.01). Aspirin (7%) had the lowest incidence of a blood transfusion followed by factor Xa inhibitors (9%), warfarin (12%), and enoxaparin (13%). There were no differences in bleeding-related complications (p = 0.81) between the groups. Aspirin use increased at a compound annual growth rate of 30%, enoxaparin at 3%, and factor Xa inhibitors at 43%, while warfarin use decreased at a compound annual growth rate of -3%.
Conclusions
Factor Xa inhibitors had the highest growth in utilization during our study period, followed by aspirin, when compared with enoxaparin and warfarin. When selected for the right patient, factor Xa inhibitors provided improved VTE prophylaxis compared with enoxaparin and warfarin, with a lower rate of blood transfusion. Aspirin provided comparable VTE prophylaxis compared with factor Xa inhibitors with improved VTE prophylaxis compared with enoxaparin and warfarin with the lowest risk of bleeding.
Level of Evidence
Level III, therapeutic study.
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