Evidence from Cochrane systematic reviews for effects of antithrombotic drugs for lower-limb revascularization. A narrative review

ABSTRACT BACKGROUND: Peripheral arterial disease (PAD) is characterized by progressive narrowing of the arterial lumen, resulting from atherosclerotic plaques. Treatment for PAD aims to control atherosclerosis and improve blood flow. Use of antiplatelet agents and anticoagulants has played important roles in helping to prevent occlusions and stenosis. OBJECTIVE: To evaluate the evidence from Cochrane systematic reviews regarding the accuracy, effectiveness and safety of use of anticoagulants and antiplatelets in lower-limb revascularization, in patients with peripheral arterial disease. METHODS: Systematic reviews found through searches in the Cochrane Library were included. Two authors evaluated whether the reviews found were in line with the inclusion criteria for this investigation. A qualitative synthesis of their findings was presented. RESULTS: Three systematic Cochrane reviews were included. Patients who underwent prosthetic bypass surgery probably presented greater benefit from use of antiplatelets, and patients who underwent vein revascularization probably presented greater benefit from use of anticoagulants. Patients who received endovascular treatment benefited from both antiplatelet and anticoagulant treatment. However, the reliability of the results found was impaired because at the time when these reviews were published, there was no mandatory assessment using the GRADE criteria. CONCLUSION: Despite the evidence found, it is necessary for these reviews to be updated in order to evaluate the degree of certainty of the results found.

Association between vitamin D levels and lower-extremity deep vein thrombosis: a case-control study

ABSTRACT BACKGROUND: Vitamin D has relationships with pathogenesis and inflammation pathways in many diseases. Its deficiency may make clinicians think not only of supplementation but also of presence of other diseases. OBJECTIVE: To investigate the relationship between vitamin D levels and deep vein thrombosis (DVT), given that reduced levels are related to increased risk of cardiovascular diseases. DESIGN AND SETTING: Case-control study conducted in the cardiovascular surgery and family medicine departments of a hospital in Turkey. METHODS: A total of 280 participants were included: 140 each in the DVT and control groups. Basic clinical characteristics, comorbidities and serum 25-hydroxyvitamin D (25(OH)D) levels were recorded and then compared between the groups. Serum 25(OH)D levels were also evaluated separately in three subgroups (sufficient, insufficient and deficient). RESULTS: Serum 25(OH)D levels were significantly lower in the DVT group than in the controls (P < 0.001). Females in the DVT group had lower 25(OH)D levels than those in the control group (P = 0.002). Nonetheless, the median 25(OH)D level (16.41 ng/ml) of the control group was still below the reference value. Logistic regression analysis showed that 25(OH)D was a significant predictor of DVT. Weight, height and body mass index, which all presented interaction, were significant in the logistic regression analysis but not in individual analyses. CONCLUSION: The serum vitamin D levels of DVT patients were lower than those of controls. If the results obtained from our study are supported by further large-scale randomized controlled trials, vitamin D replacement may be brought into the agenda for protection against DVT.

Acute renal failure due to bilateral renal vein thromboses: A rare complication of heparin-induced thrombocytopenia

Heparin-induced thrombocytopenia type II is a rare but devastating complication of heparin exposure. We review a case of a 66-year-old female who underwent aortic valve surgery requiring venoarterial extracorporeal membranous oxygenation (ECMO) support postoperatively. She subsequently developed acute renal failure due to bilateral renal vein thromboses and thrombocytopenia and was found to have platelet factor 4/heparin antibodies and was diagnosed with heparin-induced thrombocytopenia (HIT). She was transitioned to nonheparin anticoagulation and her thrombocytopenia improved. Although a rare complication of anticoagulation, diagnosing HIT in a patient on ECMO requires a high index of suspicion and should be considered.

Can Platelet Large Cell Ratio and High-sensitivity Creactive Protein be used as Predictive Markers for Vascular Complications in Type 2 Diabetes Mellitus?

Background and Aims:A large proportion of patients with diabetes mellitus suffer from preventable vascular angiopathies. Alteredplatelet structure and functions have been linked with these vascular complications. Hence, this study was undertaken to correlateplatelet indices and high-sensitivity C-reactive protein (hs-CRP) levels with glycemic control and vascular complications to assesswhether they can be used as predictive factors.Materials and Methods: A total of 56 non-diabetics (control) and 145 diabetic patients were enrolled in this study. Criteria of fastingblood glucose ?126 mg/dL/postprandial plasma glucose (2 h) levels >200 mg/dL/HbA1c ?6.5 were considered. The diabetic groupwas further subdivided into diabetics without (82) and with complication (63) on the basis of clinical presentation, investigation, andexamination. Platelet indices (mean platelet volume [MPV], platelet distribution width [PDW], and platelet large cell ratio [P-LCR])were assessed on complete blood count analyzer. hs-CRP was done qualitatively and those samples which tested positive were assessedquantitatively.Observation: All the three platelet indices assessed - MPV, PDW, and P-LCR were significantly higher in diabetics compared to nondiabetic group and increased with increasing HbA1c level. However, only P-LCR showed a significant difference between diabetics withand without complications (P = 0.002) and MPV showed a significant difference among all the subgroups when correlated with HbA1c(P ? 0.04). For hs-CRP, the difference in the values was significant among the diabetics with and without complications (P = 0.01).Conclusion: A continuous increase in the value of MPV, PDW, and P-LCR with decreasing glycemic control proves that in diabeticsongoing inflammation causes persistent generation of larger platelets with enhanced activity. P-LCR should be the indice of choice forpredicting the possibility of future complication as in our study, it was the only parameter which showed significant difference betweendiabetics with and without complications

Surgery for Bilateral Atrial Thromboses Detected in a Cancer Patient with Cerebral Infarction / 日本心臓血管外科学会雑誌

A 74-year-old man had been taking warfarin for atrial fibrillation, but warfarin was discontinued due to upper gastrointestinal bleeding. One week later, left hemiplegia occurred, and cranial magnetic resonance imaging revealed multiple cerebral infarctions. Systemic examination revealed thrombi in both atria as well as duodenal cancer. Because all of the thrombi in both atria were larger than 30 mm in diameter, the risk of embolism or sudden death was assumed to be high. Although the use of cardiopulmonary bypass for cancer patients is controversial, bilateral atrial thrombectomy was performed 4 weeks after cerebral infarction onset because reasonable survival duration was expected with surgery for duodenal cancer after thrombectomy and further treatment. The timing of and indications for surgery in this case are discussed.

Trombocitopenia aguda profunda asociada al uso de abciximab: a propósito de un caso / Acute profound thrombocytopenia associated with the use of abciximab: case report

Se presenta un paciente con angina inestable e intervención coronaria percutánea con stents, que desarrolló púrpura mucocutánea y hematoma inguinal asociados a trombocitopenia aguda profunda inducida por abciximab con nadir de 1 x 10(9)/L (1000 plaquetas/mm³), su recuperación con el tratamiento instituido y la complicación de trombosis subaguda intrastent asociada a cuenta plaquetaria funcional que requirió reintervención con angioplastía primaria y administración de tirofiban, un agente bloqueador del receptor IIb/IIIa diferente. Se realizaron estudios diagnósticos para investigar otras causas de trombocitopenia en estos pacientes que reciben heparina, antiplaquetarios como ácido acetilsalicílico y clopidogrel, asociados a bloqueadores del receptor IIb/IIIa. Se realizó una revisión de publicaciones con reporte de esta complicación.

We present the case-report of a patient with instable angina who submitted to percutaneous coronary intervention and stent place for revascularization who developed purpura and groin hematoma associated to acute profound thrombocytopenia induced by abciximab infusion with nadir platelet counts 1 x 10(9)/L (1,000 platelets/mm³), his platelet recovery with the instituted treatment and the outcome with subacute intra-stent thrombosis that was associated with functionally platelet counts that required a primary angioplasty and administration of tirofiban, a platelet glycoprotein IIb/IIIa receptor antagonist. Laboratory confirmation to exclude other causes of thrombocytopenia and its association of glycoprotein IIb/IIIa receptor antagonist with heparin, acetylsalicylic acid and clopidogrel were obtained. We perform in literature trials with this complication.

Relationship between assays of TNF-?,ICAM-1 and deep venous thromboses in patients with hip or pelvis fracture / 重庆医科大学学报

Objective:The patients undergoing operation for the fracture of hip or/and pelvis are at risks for venous thromboembolic complication.We measured the level of tumor necrosis factor-alpha(TNF-?) and intercellular adhesion molecule-1(ICAM-1) to evaluate the relation between cytokine and deep venous thromboses(DVT).Methods:28 patients of fracture of hip or/and pelvis were divided into two groups according to venography.The levels of ICAM-1 were tested with enzyme-linked immunosorbent assay(ELISA),while TNF-? were tested with radioimmunoassay at the first day after injury,and 1st,3rd,7th,12th day of postoperative period.Results:We found a marked increase of TNF-? and ICAM-1 in all the patients,and there was significant difference between the patients and normal controls (P

A Case of Primary Antiphospholipid Antibody Syndrome with Multiple Thromboses Including Thrombotic Occlusion of Abdominal Aorta

In antiphospholipid antibody syndrome (APS), multiple thromboses affecting large arteries and veins through the whole body is rare. In this report, a case of a 65 year old women suffering from APS with multiple thromboses of the renal and iliac artery, the infrarenal abdominal aorta, the deep vein, and a pulmonary thromboembolism is presented. The patient was treated successfully with intensive anticoagulation and steroid pulse therapy. There was no evidence of recurrent thrombotic complications during a three year follow-up period with oral warfarin and prednisolone

Arterial thrombosis associated with nephrotic syndrome; a case report and review (adult cases in the English literature)

The thromboembolic complications of nephrotic syndrome are reasonably common, including spontaneous peripheral venous and/or arterial, pulmonary arterial, and renal venous occlusions. However, in comparison to the relatively high incidence of the venous thromboembolic complications with hypercoagulable status, arterial thromboses have been reported much less and it was only 20 cases in the English literature so far. Furthermore, the most cases were pediatric patients rather than adults. Therefore, this report describes an adult nephrotic cases complicated by superior mesenteric artery thrombosis leading to death via catastrophic hospital course. Also, we reviewed the literature in English regarding cases of arterial thromboses in adult nephrotic patients with special interest to locations of thrombosis, underlying histopathologic types of glomerulopathy, and use of steroids or diuretics before its development.