Successful Caesarean Section on Ticagrelor Treatment One Day after Primary Percutaneous Coronary Intervention.

Caesarean section is a challenging intervention in patients treated with dual antiplatelet therapy. We present a case of a 32-year-old pregnant woman experiencing large acute myocardial infarction (MI) of the anterolateral wall, complicated by cardiogenic shock in the 38th week of pregnancy, and treated with drug-eluting stent implantation and dual antiplatelet therapy (DAPT) consisting of aspirin and ticagrelor. Less than 24 h after the MI delivery started, an urgent Caesarean section was indicated. As multiplate aggregometry testing showed a relatively insufficient level of ticagrelor platelet inhibition and a moderate level of aspirin platelet inhibition, a Caesarean section was performed without discontinuation of ticagrelor, which was decided due to the need for emergency surgery. Local hemostatic measures including administration of tranexamic acid were applied. The patient did not experience excessive bleeding. A healthy male baby was born. To the best of our knowledge, this is the first reported case of surgery in pregnant women treated with DAPT without ticagrelor discontinuation.

Rotational thromboelastometry (ROTEM) profiling of COVID-19 patients.

We evaluated coagulation abnormalities via traditional tests and rotational thromboelastometry (ROTEM) in a group of 94 patients with confirmed SARS-CoV-2 infection and different severity of pneumonia (34 moderate, 25 severe, 35 critical) with the hypothesis that ROTEM parameters differed by coronavirus disease 2019 (COVID-19) severity. Shorter than normal clotting time (CT) and higher than normal maximum clot firmness (MCF) in extrinsic rotational thromboelastometry (EXTEM) and fibrinogen rotational thromboelastometry (FIBTEM), shorter than normal EXTEM clot formation time (CFT), and higher than normal α-angle were classified as markers of hypercoagulable state. Increment in the number of patients with ≥2 hypercoagulable parameters, higher EXTEM (P = .0001), FIBTEM MCF (P = .0001) and maximum lysis decrement (P = .002) with increment in disease severity was observed (P = .0001). Significant positive correlations between IL6 and CT EXTEM (P = .003), MCF EXTEM (P = .033), MCF FIBTEM (P = .01), and negative with ML EXTEM (P = .006) were seen. Our findings based on analysis of different disease severity groups confirmed that a hypercoagulable ROTEM pattern characterized by clot formation acceleration, high clot strength, and reduced fibrinolysis was more frequent in advanced disease groups and patients with high IL6. These results supported the need for different thromboprophylaxis approaches for different severity groups.

Demographic and Clinical Factors Associated with Reactivity of Anti-SARS-CoV-2 Antibodies in Serbian Convalescent Plasma Donors.

Passive immunotherapy with convalescent COVID-19 plasma (CCP) is used as a therapeutic procedure in many countries, including Serbia. In this study, we analyzed the association between demographic factors, COVID-19 severity and the reactivity of anti-SARS-CoV-2 antibodies (Abs) in Serbian CCP donors. Individuals (n = 468) recovered from confirmed SARS-CoV-2 infection, and who were willing to donate their plasma for passive immunization of COVID-19 patients were enrolled in the study. Plasma samples were tested for the presence of IgG reactive to SARS-CoV-2 spike glycoprotein (S1) and nucleocapsid antigens. Individuals were characterized according to age, gender, comorbidities, COVID-19 severity, ABO blood type and RhD factor. Total of 420 candidates (420/468; 89.74%) reached the levels of anti-SARS-CoV-2 IgG that qualified them for inclusion in CCP donation program. Further statistical analysis showed that male individuals (p = 0.034), older age groups (p < 0.001), existence of hypertension (p = 0.008), and severe COVID-19 (p = 0.000) are linked with higher levels of anti-SARS-CoV-2 Abs. These findings will guide the selection of CCP donors in Serbia. Further studies need to be conducted to assess the neutralization potency and clinical efficiency of CCP collected from Serbian donors with high anti-SARS-CoV-2 IgG reactivity.

Effect of Intra-operative Intra-arterial Thrombolysis on Long Term Clinical Outcomes in Patients with Acute Popliteal Artery Aneurysm Thrombosis.

OBJECTIVE: Acute lower limb ischaemia (ALI) as a result of popliteal artery aneurysm (PAA) thrombosis represents a significant problem. The aim of this study was to investigate outcome of intra-operative intra-arterial thrombolysis in the treatment of acute ischaemia due to PAA thrombosis in terms of major adverse limb events (MALE), overall survival, and intrahospital complications, especially those associated with bleeding. METHODS: A total of 156 patients with Rutherford grade IIa and IIb acute ischaemia resulting from PAA thrombosis were admitted between 1 January 2011 and 1 January 2017. The patients were divided into two groups, those who underwent additional treatment with intra-operative intra-arterial thrombolysis (20 patients), and those who did not (136 patients). By using covariables from baseline and angiographic characteristics, a propensity score was calculated for each patient. Each patient who underwent intra-operative thrombolysis was matched to four patients from the non-thrombolysis group. Thus, comparable patient cohorts (20 in the thrombolysis and 80 in the non-thrombolysis group) were identified for further analysis. The primary end point was MALE and the secondary endpoint all cause mortality. RESULTS: After a median follow up of 55 months, the estimated MALE rate was significantly lower in the thrombolysis group (30% vs. 65%, chi square = 10.86, p < .001, log rank test). Also, patients in the thrombolysis group had a significantly lower mortality rate (20% vs. 42.65%, chi square = 3.65, p = .05, log rank test). The thrombolysis group had wound/haematoma related interventions performed more commonly (25% in thrombolysis vs 8%, in non-thrombolysis group), but the difference was not significant (p=.013). There were no cases of major (intracranial and gastrointestinal) bleeding in either group. CONCLUSION: The data suggest that intra-operative thrombolysis in the treatment of selected patients with ALI due to PAA thrombosis has long term MALE and overall survival benefits, without a significant risk of major, life threatening bleeding complications.

Practical Aspects of Monitoring of Antiplatelet Therapy.

Despite the application of new antiplatelet drugs (prasugrel and ticagrelor), dual antiplatelet therapy with clopidogrel and aspirin remains the standard for patients with acute coronary syndrome undergoing percutaneous coronary intervention, especially in countries of low socioeconomic status. Regardless of the proven benefits, numerous studies have shown that certain groups of patients who receive standard doses of clopidogrel and aspirin do not respond adequately, and many of them also exhibit adverse cardiovascular events. Studies have shown that the risk of stent thrombosis and ischemic complications is higher in patients with: acute coronary syndrome, diabetes mellitus, thrombocytosis, reduced systolic function of the left ventricle with ejection fraction less than 30%, presence of multiple stents, longer and thinner stents, and renal failure. In these patients it is particularly important to assess the response to clopidogrel and selecting adequate antiplatelet therapy; this provides an impetus for platelet function tests. The second especially significant group to target for laboratory evaluation includes patients with increased risk of bleeding, such as elderly patients, patients with low body weight, anemia, thrombocytopenia, renal failure, past or current ventricular or duodenal ulcer, coagulopathy, or liver disease. The third important application of platelet function tests entails the preparation and evaluation of the time for surgical interventions or invasive diagnostic procedures in patients on antiplatelet therapy. These tests can also be helpful for monitoring the effects of therapy of bleeding due to platelet dysfunction. For high-risk patients the careful selection of optimal antiplatelet drug(s) on the basis of estimated individual risk of thrombosis and bleeding, pharmacodynamic characteristics of each drug, and patient̀s comorbidity remains essential.

Comparison of two laboratory assays in monitoring the efficacy of different prophylaxis regimens for severe haemophilia.

BACKGROUND: The goal of this study was to compare the validity of two laboratory assays, rotation thromboelastometry (ROTEM) and endogenous thrombin potential (ETP), in monitoring and evaluating different prophylactic treatment regimens in patients with severe haemophilia. METHODS: Twenty adult patients with severe haemophilia were divided into three groups according to treatment regimen with concentrate of factor (F) VIII/IX: full-dose prophylaxis (5 patients), intermediate-dose prophylaxis (5 patients), and on demand treatment (10 patients). RESULTS: The ROTEM for the group treated with full-dose prophylaxis was significantly lower than ROTEM for the group treated with intermediate-dose prophylaxis (p = 0.025). Among the patients given full-dose prophylaxis, 40% (2 patients) had prolonged ROTEM after 3 months of treatment, while among those given intermediate-dose prophylaxis all patients (100%, 5 patients) had prolonged ROTEM (p = 0.038). The ETP was significantly improved after 3 months of full-dose in comparison with intermediate-dose prophylaxis (p = 0.042). CONCLUSIONS: ROTEM and ETP are useful laboratory assays for monitoring efficacy of different prophylaxis regimens with concentrate of FVIII/IX in patients with severe haemophilia, helping in making decisions regarding optimal dose-regimen prophylaxis.

Vascular graft thrombosis secondary to activated protein C resistance: a case report and literature review.

Hypercoagulability is a well-documented and prominent risk factor for venous thromboembolism. The role of thrombophilia in arterial thrombotic events is less well defined. A 52-year-old male patient with multiple atherogenic risk factors was admitted for non-healing pedal ulcer and absent distal pulses. Based on the clinical presentation, Doppler ultrasound and angiography findings, the patient underwent elective in situ bypass arterial reconstruction. The saphenous vein graft was of satisfactory quality and the procedure went routinely. Acute graft thrombosis on postoperative day 0 was recognized immediately and prompted an emergent surgical revision. No technical errors or anatomical/mechanical causes for failed reconstruction were found and the graft was successfully thrombectomized using a Fogarty balloon-catheter. Graft rethrombosis, however, ensued after several hours. Considering the absence of threatening limb ischemia and the idiopathic recurrent thrombosis, raising suspicion of prothrombotic state, conservative treatment was pursued. Postoperative thrombophilia testing proved positive for activated protein C resistance, mandating introduction of chronic oral anticoagulation. Six months later, the operated extremity is viable. Inexplicable vascular graft thrombosis, particularly if early and recurrent, should raise suspicion of underlying thrombophilia. If confirmed by laboratory testing, long-term secondary antithrombotic prophylaxis may be required.

Diagnostic relevance of ADAMTS13 activity: evaluation of 28 patients with thrombotic thrombocytopenic purpura - hemolytic uremic syndrome clinical diagnosis.

INTRODUCTION: The significance of ADAMTS13 (a disintegrin and metalloproteinase with thrombospondin motif-13) activity for diagnosis and therapy of thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS) is still a controversial issue. OBJECTIVE: The aim of this report was to analyze the value of ADAMTS13 measurements in the diagnosis of TTP and HUS. METHODS: At presentation, we analyzed patients with idiopathic TTP (n = 18), secondary TTP (n = 4), diarrhea positive HUS (n = 3) and diarrhea negative HUS (n = 3) treated in Belgrade, Serbia from 2004 to 2010. ADAMTS13 activity from acute phase samples was measured using the residual collagen binding activity assay at the Haemophilia and Thrombosis Centre, Milan, Italy. RESULTS: There was a significant correlation between reduced ADAMTS13 activity and idiopathic TTP diagnosis (p = 0.000) as well as between lower ADAMTS13 activities and higher reticulocytes (p = 0.017) and lactate dehydrogenase levels (p = 0.027). Significant correlation was also found between higher protease activity and diagnosis of HUS (p = 0.000). There was a statistically significant correlation between higher ADAMTS13 activities and higher platelets count (p = 0.002), blood urea nitrogen (p = 0.000), and creatinine level (p = 0.000). CONCLUSION: Severe ADAMTS13 deficiency points at the diagnosis of idiopathic TTP and it is present in the secondary TTP but not in HUS.

Clinical experience in treatment of thrombotic thrombocytopenic purpura--hemolytic uremic syndrome with 28 patients.

BACKGROUND: Neither optimal treatment nor significance of ADAMTS13 (A Desintegrin And Metalloprotease with ThromboSpondin type 1 repeats) activity for diagnosis and therapy of thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS) have not been defined yet. The aim of the report is to analyze response to different volumes of plasma exchange (PE), and relationship to ADAMTS13. DESIGN AND METHODS: 28 patients clinically diagnosed with idiopathic TTP (n = 18), secondary TTP (n = 4), atypical HUS (n = 3) and typical HUS (n = 3) manifested 31 acute episodes. Patients were treated with PE in 26, and with plasma transfusion in 5 episodes with additional different therapies. RESULTS: PE volumes were as follows: 1 in 7, 1.5 in 3, 2 in 14, and intensifying schedule (1 to 1.5) in 2 episodes. Procedure number was lower in patients treated with 2 and 1.5 (p = 0.019) than in those treated with 1 volume exchange and PE intensifying, respectively (p = 0.010). PE response rate was 25/26 (96.15%). Exacerbation frequency was higher in idiopathic TTP patients (3/19) treated with 1 compared with patients treated with > 1 volume exchange (p = 0.003). Survival rate was 25/28 (89.29%). ADAMTS13 activity was reduced in 22 with severe deficiency in 14 patients. CONCLUSION: Patients responded to different treatments regardless of ADAMTS13 activity, requiring less PEs with larger volume exchanges.

Some technical considerations of open thoracoabdominal aortic aneurysm repair in a transition country.

A variety of operative approaches and protective adjuncts have been used in thoracoabdominal aneurysm (TAA) repair to minimize the major complications of perioperative death and spinal cord ischemia. There is no consensus with respect to the optimal approach. We present 118 surgically treated patients over a 10-year period. The present study reviews our experience as a transition country (Serbia) in the treatment and problems we have encountered during open operative treatment of TAAs. Between 1999 and 2009, the authors reviewed 118 consecutive patients who underwent thoracoabdominal aortic resection using a variety of spinal cord protection. Clinical data collected prospectively were analyzed retrospectively. The purpose of the current study was to review the results of a large series of TAA repairs and to present some technical considerations and complications of open TAA repair. There were seven operative deaths (5.9%): two in the setting of ruptured TAAs, three myocardial infarctions and two due to hemorrhage. All 30 (25.4%) postoperative deaths occurred during the initial hospitalization. Postoperative complications included paraplegia in 11 patients (9.3%); renal failure in eight patients (6.8%), with four patients (3.4%) requiring hemodialysis; pulmonary complications in 75 patients (63.5%); bleeding requiring reoperation in two patients (1.7%) and coagulopathic hemorrhage in five patients (4.2%); cardiac complications in six patients (5.1%); stroke in five patients (4.2%); wound dehiscence in six patients (5.1%); and subdural hemorrhage in one patient (0.87%). Open TAA repair intrinsically has substantial complications, of which spinal cord ischemia and renal failure are the most devastating, despite major progress in our understanding of the pathophysiology and operative strategy. Our current review of data clearly proves that the surgical repair of TAAs remains a challenge even in the 21st century, especially in a country in transition.

Role of recombinant factor VIIa in the treatment of intractable bleeding in vascular surgery.

BACKGROUND: Most recent publications have shown that the recombinant form of activated factor VII (rFVIIa; NovoSeven, Novo Nordisk A/S, Bagsværd, Denmark) induces excellent hemostasis in patients with severe intractable bleeding caused by trauma and major surgery. The purpose of this study was to determine the influence of rFVIIa on the treatment of intractable perioperative bleeding in vascular surgery when conventional hemostatic measures are inadequate. MATERIALS AND METHODS: There were two groups of patients: the NovoSeven group (group N), 10 patients with ruptured abdominal aortic aneurysms (RAAAs) and 14 patients operated on due to thoracoabdominal aortic aneurysms (TAAAs); the control group (group C), 14 patients with RAAAs and 17 patients with TAAAs. All patients suffered intractable hemorrhage refractory to conventional hemostatic measures, while patients from group N were additionally treated with rFVIIa. RESULTS: Postoperative blood loss was significantly lower in group N treated with rFVII (P < .0001). Postoperative administration of packed red blood cells, fresh frozen plasma, and platelets was lower in patients from group N, (P < .0001). Successful hemorrhage arrest was reported in 21 patients (87.5%) treated with rFVIIa, and in 9 patients (29.03%) in group C (P < .001). Thirty-day mortality in these two groups significantly differed. The mortality rate was 12.5% (3 patients) in group N and 80.65% (25 patients) in group C (P < .0001). CONCLUSION: Our findings suggest that rFVIIa may play a role in controlling the intractable perioperative and postoperative bleeding in surgical patients undergoing a repair of RAAAs and TAAAs. Certainly, prospective randomized trials are necessary to further confirm the efficacy and cost-effectiveness of rFVIIa in these patients.

Bloodless esophageal replacement in children with corrosive esophageal strictures--report of two cases.

BACKGROUND: Esophageal replacement is major procedure with high risk for perioperative allogeneic blood transfusion (ABT), especially in pediatric patients due to nutritive deficiency, anemia, small body weight and blood volume. Autologous blood policy is particularly important in female children. METHODS: We present treatment strategy with the aim of avoiding ABT, that have been applied in two female pediatric patients with caustic stricture of thoracic esophagus. The patients were 7 and 8 years old, with body weight 34 and 23.5 kg, respectively. Protocol was based on the stimulation of haematopoetic system with erythropoietin, iron therapy and preoperative autologous blood donation (PABD). In the first patient, with a history of previous retrosternal bypass esophagocoloplasty and extraction of necrotic colonic graft, delayed reconstruction--transhiatal subtotal esophagectomy and gastric pull-up with cervical anastomosis were performed. In the second patient, repeated ineffective dilatations of esophageal stricture were reason for retrosternal left colon interposiotion and exclusion of native esophagus. RESULTS: No adverse events were attributed to preoperative blood donation period. No allogenic blood products were used during perioperative period. Both patients had uneventful postoperative course. CONCLUSION: In specialized institutions for esophageal surgery, PABD with administration of erythropoietin and iron therapy, enable bloodless esophageal replacement, even in children.

Intraoperative cell salvage versus allogeneic transfusion during abdominal aortic surgery: clinical and financial outcomes.

The objective of this study was to assess the clinical and financial outcomes of intraoperative cell salvage (ICS) during abdominal aortic surgery. In this study, 90 patients were operated on with the use of ICS (group 1, prospective) and 90 patients without ICS (group 2, historical control). According to the type of operation, the patients were subdivided into three consecutive 30-patient subgroups (1, aortoiliac occlusive disease [AOD]; 2, elective abdominal aortic aneurysm [AAA]; or 3, ruptured abdominal aortic aneurysm [RAAA]). Transfusion requirements and postoperative complications were recorded. The total amounts of perioperatively transfused allogeneic blood were higher in all patient subgroups that underwent surgery without ICS (p = .0032). In the ICS group, 50% of AOD patients and 60% of elective AAA patients received no allogeneic transfusions. There were no significant differences in the incidence of postoperative complications in any group examined. ICS significantly reduced the necessity for allogeneic transfusions during abdominal aortic surgery. ICS use was most valuable in urgent situations with high blood losses, such as RAAA, for which only small amounts of allogeneic blood were initially available. In patients with more than 3 units of autologous blood reinfused, this method was cost effective.

[Surgical treatment of abdominal tumours closely related to major blood vessels].

INTRODUCTION: Radical operative treatment of abdominal tumours closely related to major blood vessels often demands complex vascular procedures. OBJECTIVE: The aim of this paper was to present elementary principles and results of the complex procedures, based on 46 patients operated on at the Institute for Cardiovascular Diseases, Clinical Centre of Serbia, Belgrade, from January 1999 to July 2006. METHOD: Primary localisation of the tumour was the kidney in 14 patients, the suprarenal gland in 2, the retroperitoneum in 23 and the testis in 7 patients. Histologically, the most frequent were the following: renal carcinoma in 14 patients, teratoma in 7, liposarcoma in 5, fibrosarcoma and lymphoma in 3 patients. The tumour compressed abdominal aorta occurred in 3 cases, vena cava inferior in 5 and both the abdominal aorta and vena cava inferior in 11 cases. In 4 cases the tumour infiltrated the abdominal aorta, in 11 the vena cava inferior and in 8 both of them. In two patients, the tumour compressed the vena cava inferior and infiltrated the aorta; in two patients the aorta was compressed and the vena cava was infiltrated. In three cases only the exploration was performed due to multiple abdominal organ infiltration. The ex tempore biopsy showed the type of tumour in which the radical surgical treatment did not improve the prognosis. In 20 cases of tumour compression, subadventitional excision was performed. In 23 cases of infiltration, the tumour excision and vascular reconstruction had to be performed. Intraoperative blood cell saving and autotransfusion were applied in 27 patients. RESULTS: The lethal outcome happened in 3 (6.5%) patients during hospitalization. In other patients all reconstructed blood vessels were patent during the postoperative hospitalization period. CONCLUSION: Treatment of the abdominal tumours closely related to major blood vessels must be interdisciplinary, considering diagnostics, operability estimation and additional measures. Tumour reduction cannot improve long term prognosis, and has no major impact on life quality. There have been not many papers that analyse the long term results after such complex operations proving their appropriateness.

[Recombinant activated factor VII in the treatment of intractable non-surgical bleeding following major vascular procedures].

INTRODUCTION: Recombinant form of activated factor VII (rFVIIa) has been approved for use in haemophiliacs with antibodies to factor VIII or factor IX. Recent studies and clinical experiences have showed that rFVIIa gives extreme haemostatic effects in patients with severe "nonhaemophilic" bleeding produced after trauma and major surgery. OBJECTIVE: We present our preliminary experience of the use of rFVIIa in vascular surgery where conventional haemostatic measures were inadequate. METHOD: There were 17 patients divided into three groups: Group I--6 patients with ruptured abdominal aortic aneurysms; Group II--7 patients with thoracoabdominal aortic aneurysms and 1 patient with acute complicated dissection of thoracic aorta type III; Group III--3 patients with retroperitoneal tumours involving great abdominal vessels. RESULTS: Clinical improvement was reported following the treatment in 14 of 17 patients in our study. Bleeding was successfully controlled as evidenced by improved haemodynamic parameters and decreased inotrope and transfusion requirement. CONCLUSION: More liberal use of rFVIIa in vascular patients is limited, because there is no randomized controlled trial proving efficacy and safety in vascular patients. We recommend the use of rFVIIa in vascular surgery only during and after operative treatment of thoracoabdominal aortic aneurysms, ruptured abdominal aortic aneurysms and retroperitoneal tumours involving aorta and/or inferior vena cava complicated with "non-surgical" massive uncontrolled bleeding.

Salvage late plasmapheresis in a patient with pulmonary embolism caused by heparin-induced thrombocytopenia primarily resistant to danaparoid sodium and lepirudin.

We report the case of 64-year-old female patient with pulmonary embolism and bilateral femoropopliteal deep vein thrombosis caused by heparin-induced thrombocytopenia type II (HIT II) resistant to danaparoid sodium and subsequently administered lepirudin in whom a single late plasmapheresis performed on day 6 of the initiation of treatment of HIT reversed the course of the disease, preventing its highly potential fatal outcome. Primarily administered lepirudin was not only ineffective but even led to further aggravation of the patient's clinical state and platelet count drop in the first stage of the HIT treatment. The improvement of the patient's clinical state was not achieved before therapeutic plasma exchange (TPE) had removed the greatest part of pathogenetic circulating substrate. Only after TPE, lepirudin, introduced again, led to the platelet count recovery. In the subsequent course of the treatment, lepirudin was combined with an overlapping oral anticoagulant. Previously positive heparin aggregation test and fast particle gel heparin-platelet factor 4 immunoassay were normalized as well as the patient's clinical status. Early plasmapheresis, administered within 4 days of the onset of thrombocytopenia in HIT, as a beneficial therapeutic measure in certain individual cases, is indisputable. However, our results do not concur with previously reported findings of the so far most comprehensive study on plasmapheresis performed in the management of HIT with thrombosis, discrediting late plasmapheresis administered 4 days after the onset of the disease not only as ineffective, but even as an aggravating factor. Our results suggest the possible beneficial impact of late plasmapheresis as a method that may reverse a prothrombotic process and lead to a fast improvement in the patient's platelet count, especially in cases initially resistant to thrombin inhibitors.

[Treatment of 36 cases of thrombotic thrombocytopenic purpura]. / Rezultati lecenja trombozne trombocitopenijske purpure na 36 bolesnika.

Thirty-six patients (pts.) with thrombotic thrombocytopenic purpura (TTP) were treated between May 1990 and May 2003. There were 31 women and 5 men; the average age was 37 years. Twenty-five cases were idiopathic and 11 secondary (3 infection--related, 5 occurred during pregnancy and 3 were drug--associated). The mean lag period between the first symptoms and the diagnosis was 8.5 days (in 14 pts. < or = 5; in 22 > 5). On diagnosis neurological symptoms were present in 31, bleeding in 33, fever in 21 and renal impairment in 27 patients. The mean hemoglobin was 67.5 g/L, the mean platelet count was 10 x 10(9)/L, and the mean reticulocytosis was 17%. The mean serum LDH was 1457 IU. Treatment included plasma exchange (PE) in 24 pts. and only plasma infusions in 12 pts. There were 24 complete responders (20 on PE) and 12 deaths (4 on PE); PE significantly improved survival (p < 0.01). There were 5 treatment-related complications due to the infection and bleeding, 17 exacerbations and 4 relapses. The mean time delay before the onset of symptoms and the treatment initiation lasted for 9 days suggesting the poor disease recognition; the mean time delay from diagnosis to PE institution was 6 days, indicating postponed PE. The mean treatment duration in all patients was 18 days; the mean number of PE cycles needed for the platelet count stabilization was 9. Good prognostic indicators of survival were: the longer prodromal period (> 5 days), the secondary form of TTP and the absence of coma at presentation. The use of PE significantly improved survival. TTP is a severe disorder requiring early recognition and diagnosis in general medical care facilities, which should lead to the timely treatment with PE.