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Journal of Vascular Surgery Sep 2022Natural history and duplex ultrasound (DU) findings of pediatric lower extremity arterial thrombosis (PLEAT) are not well-defined. We describe acute and short-term DU...
OBJECTIVES
Natural history and duplex ultrasound (DU) findings of pediatric lower extremity arterial thrombosis (PLEAT) are not well-defined. We describe acute and short-term DU findings of PLEAT to aid duplex interpretation and patient management.
METHODS
From August 2018 to April 2021 children with suspected PLEAT were identified prospectively. All had DU studies and were divided into group 1 (with DU-confirmed PLEAT) and group 2 (without DU-confirmed PLEAT). Patient demographics and DU findings were compared. Those with PLEAT and follow-up DU studies were also evaluated for recanalization and post recanalization DU findings.
RESULTS
We included 76 children (102 limbs) who had suspected PLEAT; 32 in group 1 and 44 group in 2. Fifty-seven percent had congenital heart disease, 26% a history prematurity (87%, 34% group 1; 11%, 14% group 2), with 14% of group 1 premature at PLEAT diagnosis and 68% aged less than 3 years-29 (94%) in group 1 and 23 (52%) in group 2. None had an arterial procedure to restore flow. Limb salvage was 100% with five group 1 mortalities unrelated to PLEAT. In group 1, 12 PLEATs were associated with an arterial line and 15 with cardiac catheterization. Occluded arteries included 7 external iliac, 20 common femoral, and 5 superficial femoral arteries (SFA). Peak systolic velocities (PSVs) distal to occluded segments in group 1 were lower than corresponding group 2 PSVs. SFA 18 ± 21 cm/s vs 84 ± 39 cm/s; popliteal artery (PA) 24 ± 18 cm/s vs 78 ± 38 cm/s; posterior tibial artery (PTA) 10 ± 8 cm/s versus 49 ± 27 cm/s (all P < .001). Twenty-one patients in group 1 had follow-up studies. Twelve (57%) were recanalized: 4 (19%) in less than 1 week and 10 (48%) by 6 months. Eighty-one percent of PLEATs were treated with anticoagulation (AC) and 57% recanalized. Fifty-nine percent of patients on AC recanalized, and 60% not on AC recanalized. Age, primary diagnosis, instrumentation type, and AC were not associated with failure to recanalize. After recanalization, PSVs in the CFA were not different than PSVs found in group 2 in the CFA (109 ± 50 cm/s vs 107 ± 57 cm/s; P = .88), but remained decreased in the SFA, PA, and PTA (SFA 68 ± 32 cm/s vs 83 ± 38 cm/s [P = .04]; PA 33 ± 13 cm/s vs 78 ± 37 [P = .0004]; and PTA 21 ± 8 cm/s vs 43 ± 20 cm/s [P = .0008]).
CONCLUSIONS
PLEAT occurs in young children, results in low distal PSVs, and often does not recanalize, but does not lead to short-term limb loss or mortality or necessarily require AC for recanalization. Normalization of CFA PSVs indicates recanalization while PSVs in segments distal to the CFA do not seem to return to normal.
Topics: Blood Flow Velocity; Child; Child, Preschool; Embolism; Femoral Artery; Humans; Lower Extremity; Peripheral Arterial Disease; Popliteal Artery; Retrospective Studies; Thrombosis; Ultrasonography, Doppler, Duplex; Vascular Patency
PubMed: 35605798
DOI: 10.1016/j.jvs.2022.04.024 -
Arteriosclerosis, Thrombosis, and... Apr 2024Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare form of pulmonary hypertension characterized by the presence of organized thrombi that obstruct pulmonary... (Review)
Review
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare form of pulmonary hypertension characterized by the presence of organized thrombi that obstruct pulmonary arteries, ultimately leading to right heart failure and death. Among others, impaired angiogenesis and inflammatory thrombosis have been shown to contribute to the progression of CTEPH. In this review, we summarize the 2-faced nature of angiogenesis in both thrombus formation and resolution in the context of CTEPH and highlight the dual role of angiogenesis and neovascularization in resolving venous thrombi. Furthermore, we discuss relevant in vitro and in vivo models that support the benefits or drawbacks of angiogenesis in CTEPH progression. We discuss the key pathways involved in modulating angiogenesis, particularly the underexplored role of TGFβ (transforming growth factor-beta) signaling in driving fibrosis as an integral element of CTEPH pathogenesis. We finally explore innovative treatment strategies that target angiogenic pathways. These strategies have the potential to pioneer preventive, inventive, or alternative therapeutic options for patients with CTEPH who may not qualify for surgical interventions. Moreover, they could be used synergistically with established treatments such as pulmonary endarterectomy or balloon pulmonary angioplasty. In summary, this review emphasizes the crucial role of angiogenesis in the development of in fibrothrombotic tissue, a major pathological characteristic of CTEPH.
Topics: Humans; Hypertension, Pulmonary; Pulmonary Embolism; Angiogenesis; Pulmonary Artery; Thrombosis; Chronic Disease; Endarterectomy
PubMed: 38328933
DOI: 10.1161/ATVBAHA.123.319852 -
Blood Advances Mar 2022Blood clots and thrombi undergo platelet-driven contraction/retraction followed by structural rearrangements. We have established quantitative relationships between the...
Blood clots and thrombi undergo platelet-driven contraction/retraction followed by structural rearrangements. We have established quantitative relationships between the composition of blood clots and extent of contraction to determine intravital contraction of thrombi and emboli based on their content. The composition of human blood clots and thrombi was quantified using histology and scanning electron microscopy. Contracting blood clots were segregated into the gradually shrinking outer layer that contains a fibrin-platelet mesh and the expanding inner portion with compacted red blood cells (RBCs). At 10% contraction, biconcave RBCs were partially compressed into polyhedral RBCs, which became dominant at 20% contraction and higher. The polyhedral/biconcave RBC ratio and the extent of contraction displayed an exponential relationship, which was used to determine the extent of intravital contraction of ex vivo thrombi, ranging from 30% to 50%. In venous thrombi, the extent of contraction decreased gradually from the older (head) to the younger (body, tail) parts. In pulmonary emboli, the extent of contraction was significantly lower than in the venous head but was similar to the body and tail, suggesting that the emboli originate from the younger portion(s) of venous thrombi. The extent of contraction in arterial cerebral thrombi was significantly higher than in the younger parts of venous thrombi (body, tail) and pulmonary emboli but was indistinguishable from the older part (head). A novel tool, named the "contraction ruler," has been developed to use the composition of ex vivo thrombi to assess the extent of their intravital contraction, which contributes to the pathophysiology of thromboembolism.
Topics: Arteries; Blood Platelets; Fibrin; Humans; Pulmonary Embolism; Thrombosis
PubMed: 34972200
DOI: 10.1182/bloodadvances.2021005801 -
The Journal of Emergency Medicine May 2021Patients with coronavirus disease 2019 (COVID-19) commonly present with fever, constitutional symptoms, and respiratory symptoms. However, atypical presentations are...
BACKGROUND
Patients with coronavirus disease 2019 (COVID-19) commonly present with fever, constitutional symptoms, and respiratory symptoms. However, atypical presentations are also well known. Though isolated mesenteric arterial occlusion associated with COVID-19 has been reported in literature, combined superior mesenteric arterial and venous thrombosis is rare. We report a case of combined superior mesenteric arterial and venous occlusion associated with COVID-19 infection.
CASE REPORT
We report a case of a 45-year-old man who was a health care worker who presented to the emergency department with severe abdominal pain. The clinical examination was unremarkable, but imaging revealed acute mesenteric ischemia caused by superior mesenteric artery and superior mesenteric vein occlusion. Imaging of the chest was suggestive of COVID-19 infection, which was later confirmed with reverse transcription polymerase chain reaction of his nasopharyngeal swab. To date, only 1 case of combined superior mesenteric artery and superior mesenteric vein thrombosis caused by COVID-19 has been reported. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: During the COVID-19 pandemic it is important to keep mesenteric ischemia in the differential diagnosis of unexplained abdominal pain. Routinely adding high-resolution computed tomography of the chest to abdominal imaging should be considered in patients with acute abdomen because it can help to identify COVID-19 immediately. © 2020 Elsevier Inc.
Topics: Abdominal Pain; COVID-19; COVID-19 Nucleic Acid Testing; Female; Humans; Intestines; Laparotomy; Male; Mesenteric Arteries; Mesenteric Artery, Superior; Mesenteric Ischemia; Mesenteric Vascular Occlusion; Mesenteric Veins; Middle Aged; Nasopharynx; Pandemics; Radiography, Thoracic; Real-Time Polymerase Chain Reaction; Reverse Transcriptase Polymerase Chain Reaction; SARS-CoV-2; Thrombectomy; Thrombosis; Tomography, X-Ray Computed; Treatment Outcome; Venous Thrombosis
PubMed: 33581991
DOI: 10.1016/j.jemermed.2020.12.016 -
Medicine Nov 2019The umbilical cord is the way to exchange gas, supply nutrients, excrete metabolized. Thrombosis of the umbilical cord leads to fetal hypoxia, which jeopardizes fetal...
RATIONALE
The umbilical cord is the way to exchange gas, supply nutrients, excrete metabolized. Thrombosis of the umbilical cord leads to fetal hypoxia, which jeopardizes fetal health and can cause fetal death. Umbilical vessel thrombosis, which is rarely reported, is difficult to detect prenatally.
PATIENT CONCERNS
Both pregnant women had an unremarkable pregnancy course until a routine ultrasound scan in the third trimester showed a single umbilical artery. However, one umbilical vein and 2 umbilical arteries were seen during an ultrasound examination at 32 weeks. Case 2 had a better pregnancy outcome because of the timely discovery of this complication.
DIAGNOSIS
Both cases were diagnosed as umbilical artery thrombosis.
INTERVENTIONS
The first patient received no interventions until they reported decreased fetal movements and gradually disappear. The second patient underwent an emergency cesarean section.
OUTCOMES
In Case 1, an emergency ultrasound examination showed intrauterine fetal death, and the patient vaginally delivered a stillborn child weighing 3300 g in a day. In Case 2, a female neonate weighing 2860 g was delivered by cesarean section, and exhibited Apgar scores of 10 and 10 at 1 and 5 minutes.
CONCLUSION
In the late-term abortions, obstetricians should be vigilant if ultrasound imaging shows suspected umbilical vascular thrombosis or shows 1 umbilical artery when there had previously been 2. The fetus should be closely monitored and interventions implemented as early as possible to improve the prenatal detection rate of umbilical vessel thrombosis and avoid adverse pregnancy outcomes.
Topics: Adult; Cesarean Section; Early Medical Intervention; Emergency Medical Services; Female; Fetal Death; Fetal Monitoring; Humans; Infant, Newborn; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Outcome; Stillbirth; Thrombosis; Ultrasonography, Prenatal; Umbilical Arteries
PubMed: 31770267
DOI: 10.1097/MD.0000000000018170 -
Blood May 2017Red blood cells (RBCs) demonstrate procoagulant properties in vitro, and elevated hematocrit is associated with reduced bleeding and increased thrombosis risk in humans....
Red blood cells (RBCs) demonstrate procoagulant properties in vitro, and elevated hematocrit is associated with reduced bleeding and increased thrombosis risk in humans. These observations suggest RBCs contribute to thrombus formation. However, effects of RBCs on thrombosis are difficult to assess because humans and mice with elevated hematocrit typically have coexisting pathologies. Using an experimental model of elevated hematocrit in healthy mice, we measured effects of hematocrit in 2 in vivo clot formation models. We also assessed thrombin generation, platelet-thrombus interactions, and platelet accumulation in thrombi ex vivo, in vitro and in silico. Compared with controls, mice with elevated hematocrit (RBC) formed thrombi at a faster rate and had a shortened vessel occlusion time. Thrombi in control and RBC mice did not differ in size or fibrin content, and there was no difference in levels of circulating thrombin-antithrombin complexes. In vitro, increasing the hematocrit increased thrombin generation in the absence of platelets; however, this effect was reduced in the presence of platelets. In silico, direct numerical simulations of whole blood predicted elevated hematocrit increases the frequency and duration of interactions between platelets and a thrombus. When human whole blood was perfused over collagen at arterial shear rates, elevating the hematocrit increased the rate of platelet deposition and thrombus growth. These data suggest RBCs promote arterial thrombosis by enhancing platelet accumulation at the site of vessel injury. Maintaining a normal hematocrit may reduce arterial thrombosis risk in humans.
Topics: Animals; Antithrombin III; Arteries; Blood Coagulation; Blood Platelets; Female; Hematocrit; Humans; Male; Mice; Peptide Hydrolases; Shear Strength; Thrombosis; Vascular System Injuries
PubMed: 28251913
DOI: 10.1182/blood-2016-10-746479 -
European Journal of Vascular and... Nov 2020Radical excision of retroperitoneal or intra-abdominal soft tissue sarcomas may necessitate vessel resection and reconstruction. The aim of this study was to assess... (Review)
Review
Multidisciplinary Oncovascular Surgery is Safe and Effective in the Treatment of Intra-abdominal and Retroperitoneal Sarcomas: A Retrospective Single Centre Cohort Study and a Comprehensive Literature Review.
OBJECTIVE
Radical excision of retroperitoneal or intra-abdominal soft tissue sarcomas may necessitate vessel resection and reconstruction. The aim of this study was to assess surgical results of retroperitoneal or intra-abdominal sarcomas involving major blood vessels.
METHODS
This was a retrospective single centre cohort study and a comprehensive review of literature. Patients with retroperitoneal or intra-abdominal sarcomas treated by the oncovascular team in Helsinki University Hospital from 2010 to 2018 were reviewed for vascular and oncological outcomes. A comprehensive literature review of vascular reconstructions in patients with retroperitoneal sarcoma was performed.
RESULTS
Vascular reconstruction was performed in 17 patients, 11 of whom required arterial reconstructions. Sixteen of the operations were sarcoma resections; the post-operative diagnosis for one patient was thrombosis instead of the presumed recurrent leiomyosarcoma. Early graft thrombosis occurred in two venous and one arterial reconstruction. Late thrombosis was detected in three (18%). The median follow up was 27 (range 0-82) months. Of the patients with sarcoma resections 5 (31%) died of sarcoma and further 4 (25%) developed local recurrence or new distant metastases. The comprehensive review of literature identified 37 articles with 110 patients, 89 of whom had inferior vena cava reconstruction only. Eight arterial reconstructions were described. Late graft thrombosis occurred in 14%. The follow up was 0-181 months, during which 57% remained disease free and 7% died of sarcoma.
CONCLUSION
Vascular reconstructions enable radical resection of retroperitoneal and intra-abdominal sarcomas in patients with advanced disease. The complex operations are associated with an acceptable rate of serious peri-operative complications and symptomatic thrombosis of the repaired vessel is rare. However, further studies are needed to assess the performance of the vascular reconstructions in the long term.
Topics: Adult; Aged; Arteries; Blood Vessel Prosthesis Implantation; Female; Follow-Up Studies; Graft Occlusion, Vascular; Humans; Male; Middle Aged; Neoplasm Staging; Postoperative Complications; Retroperitoneal Neoplasms; Retroperitoneal Space; Retrospective Studies; Sarcoma; Thrombosis; Treatment Outcome; Vascular Patency; Vena Cava, Inferior
PubMed: 32741678
DOI: 10.1016/j.ejvs.2020.05.029 -
Journal of Thrombosis and Haemostasis :... Jun 2015The potential relevance of murine atherothrombosis models for understanding human disease has been debated in the past. Despite this, in the last decade, many thrombosis... (Review)
Review
The potential relevance of murine atherothrombosis models for understanding human disease has been debated in the past. Despite this, in the last decade, many thrombosis studies with atherogenic Apoe(-/-) mice have been performed, which provide novel insight into the molecular mechanisms by which platelet and coagulation processes accomplish acute thrombus formation after plaque disruption in vivo. Support for these mechanisms has come from whole blood flow perfusion studies over plaque material in vitro, which are also reviewed in this study. The main plaque-derived triggers for thrombus formation appear to be collagen and tissue factor, next to bioactive mediators such as prostaglandin E2. The atherothrombotic process relies on collagen- and ADP-receptor-induced platelet activation as well as on thrombin/fibrin generation via the extrinsic and intrinsic coagulation pathways. Less is known of the persistent effects of a thrombus on atherosclerosis progression, but evidence suggests roles herein of activated platelets and ongoing thrombin generation.
Topics: Animals; Apolipoproteins E; Arteries; Atherosclerosis; Blood Coagulation; Blood Platelets; Collagen; Disease Models, Animal; Fibrinolysis; Humans; Mice, Knockout; Plaque, Atherosclerotic; Plasminogen Activator Inhibitor 1; Platelet Activation; Rupture, Spontaneous; Signal Transduction; Thrombosis
PubMed: 26149036
DOI: 10.1111/jth.12972 -
BMJ Case Reports Jan 2022Vaccine-induced immune thrombotic thrombocytopenia (VITT) rarely develops after many COVID-19 vaccines. A 51-year-old woman re-presented to hospital with a 4 day...
Vaccine-induced immune thrombotic thrombocytopenia (VITT) rarely develops after many COVID-19 vaccines. A 51-year-old woman re-presented to hospital with a 4 day history of headache, vomiting, diarrhoea and left calf pain, 11 days after her first dose of ChAdOx1nCoV-19 (AstraZenica) vaccine. Her neurological examination was normal. Blood tests demonstrated a low platelet count, raised D-dimer and CRP, and a positive heparin/anti-PF4 antibody assay. CT venogram demonstrated widespread cerebral venous sinus thrombosis. She was commenced on fondaparinux and intravenous immunoglobulins. The following day she developed an asymmetric quadriplegia and aphasia. CT angiogram demonstrated new bilateral cervical internal carotid artery (ICA) thrombi. She underwent stent-retriever mechanical thrombectomy of bilateral ICA and cerebral venous sinuses. Next day she had right hemiparesis and expressive dysphasia, which are improving. Thromboses due to VITT can progress rapidly to involve cerebral arteries and venous sinuses, and may warrant urgent arterial and venous thrombectomy to reduce morbidity and mortality.
Topics: COVID-19; COVID-19 Vaccines; Female; Humans; Middle Aged; SARS-CoV-2; Thrombocytopenia; Thrombosis; Venous Thrombosis
PubMed: 35042731
DOI: 10.1136/bcr-2021-245445 -
The Journal of Cardiovascular Surgery Jun 2023All endovascular procedures need an effective anticoagulation regimen that avoids thrombo-embolic complications due to the insertion and manipulation of various... (Review)
Review
All endovascular procedures need an effective anticoagulation regimen that avoids thrombo-embolic complications due to the insertion and manipulation of various intravascular devices. Systemic heparinization reduces the risk of thrombosis but there is no conclusive evidence regarding the correct use of anticoagulant medications and accordant monitoring, especially in endovascular peripheral arterial procedures. Anticoagulation must be maintained during the whole vascular procedure, especially during partial or complete blood flow interruption. Reaching and maintaining the correct coagulative status is mandatory to avoid or reduce thromboembolic complications that could limit the procedure's effectiveness or be harmful to the patient. Patients' baseline variables and procedure-related elements can influence the way anticoagulation should be administered and how coagulative status has to be monitored. This review aimed to clarify the critical points of anticoagulation and monitoring management for non-cardiac arterial procedures in order to understand the best way to manage vascular procedures anticoagulation.
Topics: Humans; Anticoagulants; Blood Coagulation; Thromboembolism; Thrombosis; Arteries; Endovascular Procedures
PubMed: 37260152
DOI: 10.23736/S0021-9509.23.12703-0