Risks and benefits of continuation and discontinuation of aspirin in elective craniotomies: a systematic review and pooled-analysis.

BACKGROUND/AIM: Discontinuation of aspirin (ASA) prior to elective craniotomies is common practice. However, patients treated with ASA for secondary prevention bear a higher risk for thromboembolic complications. Aim of this systematic review is to investigate the risks and benefits of perioperative continuation and discontinuation of ASA in elective craniotomies. METHODS: PubMed and Embase databases were searched. Inclusion criteria were retro- and prospective studies, reporting hemorrhagic and thromboembolic complications in patients in whom ASA was either continued or discontinued perioperatively in elective craniotomies. We excluded shunt operations and emergency cases. The MINORS (Methodological index for non-randomized studies) score was used to quantify the methodological quality of the eligible studies. RESULTS: Out of 523 publications, 7 met the eligibility criteria (cumulative cohort of 646 patients). The mean MINORS score for the comparative studies was 18.7/24 (± SD 2.07, range: 17-22) and 9/16 for the unique non-comparative study, indicating an overall weak methodological quality of the included studies. 57.1% of the patients underwent craniotomy for intra- and extra-axial tumor removal, 39.0% for bypass surgery and 3.9% for neurovascular lesions (other than bypass). In 31.0% of the cases, ASA was prescribed for primary and in 69.0% for secondary prevention. ASA was continued perioperatively in 61.8% and discontinued in 38.2% of the cases. The hemorrhagic complication rate was 3% (95% CI [0.01-0.05]) in the ASA continuation group (Con-Group) and 3% (95% CI [0.01-0.09]) in the discontinuation group (Disc-Group) (p = 0.9). The rate of thromboembolic events in the Con-Group was 3% (95% CI [0.01-0.06]) in comparison to 6% (95% CI [0.02-0.14]) in the Disc-Group (p = 0.1). CONCLUSION: Perioperative continuation of ASA in elective craniotomies does not seem to be associated with an increased hemorrhagic risk. The potential beneficial effect of ASA continuation on thromboembolic events needs to be further investigated in patients under ASA for secondary prevention.

Successful percutaneous extraction of malpositioned pacemaker lead in the left ventricle after proper dabigatran treatment.

Malpositioned pacemaker lead in the left ventricle (LV) is a rare procedural complication, which causes a special risk of thromboembolic events. Hence, prompt identification and early management of misplaced leads inside the LV is critical. Herein, we present a case of malpositioned pacemaker lead with transient ischemic attacks after the pacemaker implantation. The misplaced ventricular lead was discovered during regular echocardiography. Both leads were extracted percutaneously after dabigatran treatment. To our knowledge, this is the first report of uncomplicated percutaneous extraction of an inadvertently placed LV lead after dabigatran treatment. No neurologic events during a follow-up of 4 years.

Diagnosis and treatment of the rare procedural complication of malpositioned pacing leads in the left heart: a single center experience.

Objectives. This study assessed the management approach and outcome of the pacemaker or implantable cardioverter-defibrillator (ICD) leads malpositioned in the left heart. Malpositioned leads (MPLs) may have deleterious consequences, and appropriate management remains uncertain. Methods. The study population included all patients referred to a single institution for MPL in the left side of the heart after pacemaker or ICD implantation during the period from 2015 to 2021. The approach and outcome of lead management were retrospectively assessed. Results. During the study period, 6887 patients underwent device implantation. MPL was diagnosed in five patients (0.07%). In four cases, the pacing lead was placed in a coronary sinus (CS) branch, while the pacing lead was inside the left ventricle (LV) in one case. Symptoms suggestive of lead malposition were reported by 2 patients (40%). One of the patients presented with recurrent TIAs. Another presented with inappropriate ICD shocks. In one asymptomatic case, an ICD lead changed position from the right ventricle to the CS, suggesting idiopathic lead migration. In 4/5 patients, the leads were removed or repositioned by percutaneous approach, with no major periprocedural complications. Conclusions. In this series of MPL in the left heart, two patients presented with thromboembolic events or inappropriate ICD shocks. These serious complications highlight the critical need for early correct diagnosis and proper management of MPL.

A rare case of a right common iliac venous aneurysm imitating a neoplastic tumour.

BACKGROUND: Aneurysms of the deep lower limbs veins are extremely rare. Diagnosis of such conditions may be confusing and suggest the presence of a neoplastic lesion. CASE PRESENTATION: We herein report a case of a 68-year-old woman who was admitted with a large vein tumour revealed by sonography and computed tomography. A direct phlebography revealed a large venous aneurysm of the right common iliac vein with an adhering thrombus and a large collateral circulation. Anticoagulant treatment and compression with an elastic stocking were initiated because the patient refused surgical treatment. A 2-year follow-up showed no aneurysm growth or thromboembolic complications. CONCLUSIONS: We show herein that conservative management can be effective and safe in cases of this rare condition.

Bilateral Simultaneous Central Retinal Vein Occlusion Secondary to COVID-19: A Case Report.

Herein, we report a case of bilateral simultaneous central retinal vein occlusion (CRVO) secondary to coronavirus disease 2019 (COVID-19). A 48-year-old man, with hypertension, type 2 diabetes mellitus, and stage 4 chronic kidney disease, diagnosed with COVID-19 1 month ago presented to the ophthalmology department with blurred vision in both eyes for 2 weeks. Ocular examination revealed a classic clinical presentation of CRVO in both eyes. Optical coherence tomography revealed increased central macular thickness with intraretinal and subretinal fluid in both eyes. Laboratory data revealed elevated D-dimer and C-reactive protein (CRP) levels. The levels of other hypercoagulability markers were normal. The patient received intravitreal anti-vascular endothelial growth factor therapy in both eyes, followed by regular follow-up every month until complete resolution of symptoms and gradual improvement of the retinal vascular appearance. COVID-19 can cause a variety of coagulation abnormalities and thromboembolic complications such as bilateral simultaneous CRVO. Clinicians and patients should be aware of ocular symptoms and presentations that are probably associated with COVID-19.

Three-dimensional reconstruction imaging by C-arm computed tomography accurately visualizes in-stent neointimal formation in patients with stent-assisted coil embolization.

Background: Stent apposition to the vessel wall and in-stent neointimal formation after stent-assisted coil embolization for intracranial aneurysm are important factors associated with postoperative thromboembolic complications. No assessment methods have been established to depict 3-dimensional (3D) all-round in-stent neointimal formation. Objective: To demonstrate the superiority of Dyna-3D imaging assessment as a modality for all-round ISNF in comparison with conventional two-dimensional digital subtraction angiography (2D-DSA). Methods: Consecutive patients who underwent braided stent-assisted coil embolization for unruptured aneurysm between November 2016 and September 2021 were enrolled. Radiological assessments for stent apposition to the parent vessel after stent deployment and in-stent neointimal formation after 3 months were obtained. Dyna-3D was reconstructed by overlapping a plain image showing stent struts with a rotational DSA image showing the vessel lumen. Reconstructed Dyna-3D images can be rotated to any angle on the screen to evaluate to stent apposition around the vessel and in-stent neointimal formation in 3D, for comparison with 2D-DSA evaluations. Results: Among the 73 patients enrolled, 70 patients (96%) showed complete stent wall apposition on Dyna-3D. Higher intra-rater agreement was confirmed on assessment of in-stent neointimal formation with Dyna-3D (Cohen's κ = 0.811) than with conventional 2D-DSA (Cohen's κ = 0.517). in-stent neointimal formation could not be confirmed on conventional imaging in 9 cases (16%) and on Dyna-3D in 2 cases (3%). The number of in-stent neointimal formations rated as stent wire completely outside the endothelial line was significantly higher with Dyna-3D than with 2D-DSA (p = 0.0001). Conclusion: All-round 3D evaluation by Dyna-3D imaging appears useful for confirming in-stent neointimal formation after braided stent deployment in patients after stent-assisted coil embolization.

Perioperative Antithrombotic Management During Gastroenterological Surgery in Patients With Thromboembolic Risks: Current Status and Future Prospects.

Antiplatelet medicines and anticoagulants are two types of antithrombotic pharmaceuticals, with anticoagulants including warfarin and direct oral anticoagulants (DOACs). During the perioperative phase, patients receiving antithrombotic therapy must balance two risks: bleeding and thromboembolism. To date, there are no defined recommendations for antithrombotic drug management in gastroenterological (GE) surgery, and the management strategy varies greatly between hospitals. The perioperative treatment of antithrombotic medications should be centralized according to the mechanism of each drug, and a suitable management strategy should be established. The proposed perioperative management for patients undergoing antithrombotic therapy is as follows: (1) in the case of antiplatelet medication, aspirin monotherapy is continued; (2) for patients on warfarin, it is substituted by DOAC bridging (preferred) or heparin bridging; and (3) in the case of DOACs, the short-term withdrawal of DOACs (typically 1-2 days) without heparin bridging is indicated. In the current review, the current state and future prospects of perioperative antithrombotic medication treatment during gastroenterological surgery are discussed.

Predictors of thromboembolic complications after stent-assisted coiling of acutely ruptured intracranial aneurysms: A retrospective multicenter study.

Background: Stent-assisted coiling (SAC) has been reported to safely and effectively treat wide-necked unruptured intracranial aneurysms. However, SAC of acutely ruptured aneurysms is controversial because of perioperative thromboembolic complications. We aimed to investigate the predictors of the thromboembolic complications after SAC of acutely ruptured aneurysms. Methods: We performed a retrospective multicenter analysis of 110 consecutive patients with ruptured intracranial aneurysms treated with SAC within 72 h of the onset of subarachnoid hemorrhage. Thromboembolic complications were defined as any angiographic filling defects at the aneurysms base or the distal artery during the stent treatment and the new onset of symptomatic ischemia and a new hypo-density in a vascular distribution confirmed by CT scan within 24 h of treatment. These patients were grouped into patients with thromboembolic complications and those without thromboembolic complications. A multivariate logistic regression analysis was performed to identify predictors of thromboembolic complications. Results: One hundred and one patients with 101 ruptured aneurysms were included in this study. 9 (8.9%) patients experienced thromboembolic complications. Patients with thromboembolic complications had a higher rate of unfavorable outcomes at discharge (P < 0.001) and at the last follow-up (p = 0.017). Of these patients, four patients presented with intraprocedural thrombus formation, and 5 experienced postprocedural ischemia. There was a trend toward thromboembolic complications in patients with a higher Fisher grade (p = 0.076) and those treated with intravenous tirofiban (p = 0.052). Patients with thromboembolic complications more often presented with poor grade clinical conditions (p = 0.005) and aneurysms with a large dome to neck ratio (p = 0.031). In the multivariate analysis, a worse World Federation World Federation of Neurological Societies (WFNS) grade (OR = 8.241; 95% CI 1.686-40.292; P = 0.009) and a larger dome to neck ratio (OR = 5.385; 95% CI 1.023-28.337; P = 0.047) were independent predictors of thromboembolic complications. Conclusion: Patients with thromboembolic complications are more likely to have an unfavorable outcome. A worse clinical condition before the treatment and a larger dome to neck ratio were independent predictors of thromboembolic complications after SAC of acutely ruptured intracranial aneurysms.

Impact of Antithrombotic Therapy on the Outcome of Patients Undergoing Laparoscopic Colorectal Cancer Surgery: A Systematic Literature Review.

In recent years, many operations have been performed as laparoscopic surgeries in the field of gastrointestinal surgery, but the effect of antithrombotic therapy (ATT) on hemorrhagic complications in patients who have undergone laparoscopic colorectal cancer surgery remains unknown. In addition, the efficacy and safety of pharmacotherapy for the prevention of venous thromboembolism (VTE) have not yet been concluded. The purpose of this systematic review study is to clarify the effect of ATT on hemorrhagic complications in patients undergoing laparoscopic colorectal cancer surgery. Articles published between 2013 and 2020 were searched on Google Scholar and PubMed, and research regarding ATT and laparoscopic colorectal cancer surgery was included after a thorough examination of each study. Each study yielded information on the study's design, type of surgical procedures, antithrombotic medications used, and surgical outcomes (both thromboembolic and hemorrhagic consequences). This systematic review comprised 20 published papers, including a total of 12,751 patients who received laparoscopic colorectal cancer surgery. Four studies on thrombosis prevention in VTE were randomized clinical trials, and the other 16 were cohort or case-control studies. For the effects of prolonged use of ATT on hemorrhagic complications, most studies demonstrated that laparoscopic colorectal cancer surgery with continued preoperative aspirin could be safely conducted without an increase in the frequency of bleeding complications. On the other hand, most included papers have shown that patients receiving VTE pharmacoprophylaxis may be at an increased risk of bleeding complications, but its effectiveness has not been statistically proven, especially in the Asian patient population. Laparoscopic colorectal cancer surgery in patients on prolonged ATT can be safely conducted with no increase in the incidence of hemorrhagic or thrombotic complications. The efficacy and safety of VTE pharmacoprophylaxis in laparoscopic colorectal surgery is still at issue. It is necessary to establish available protocols or guidelines by validating reliable studies.

How to Optimize Cardioversion of Atrial Fibrillation.

Cardioversion (CV) is an essential component of rhythm control strategy in the treatment of atrial fibrillation (AF). Timing of CV is an important manageable factor in optimizing the safety and efficacy of CV. Based on observational studies, the success rate of CV seems to be best (≈95%) at 12−48 h after the onset of arrhythmic symptoms compared with a lower success rate of ≈85% in later elective CV. Early AF recurrences are also less common after acute CV compared with later elective CV. CV causes a temporary increase in the risk of thromboembolic complications. Effective anticoagulation reduces this risk, especially during the first 2 weeks after successful CV. However, even during therapeutic anticoagulation, each elective CV increases the risk of stroke 4-fold (0.4% vs. 0.1%) during the first month after the procedure, compared with acute (<48 h) CV or avoiding CV. Spontaneous CVs are common during the early hours of AF. The short wait-and-see approach, up to 24−48 h, is a reasonable option for otherwise healthy but mildly symptomatic patients who are using therapeutic anticoagulation, since they are most likely to have spontaneous rhythm conversion and have no need for active CV. The probability of early treatment failure and antiarrhythmic treatment options should be evaluated before proceeding to CV to avoid the risks of futile CVs.

Thrombotic risk in gastroenteropancreatic neuroendocrine tumor patients: a single-center experience.

BACKGROUND: Only scanty specific studies are available on venous thromboembolism (VTE) in neuroendocrine neoplasms (NEN). We retrospectively assessed the incidence of VTE in gastroenteropancreatic (GEP) NEN patients. METHODS: Between 2000 and 2016, GEP-NEN patients were retrospectively evaluated for VTE. Major thrombotic events included deep venous thrombosis (DVT) and pulmonary embolism (PE). 160 patients were included. The primary tumor site was: the gut in 99, pancreas in 54, and unknown in 7. A total of 93 patients had grade (G) 1 tumor, 36 G2, 4 G3; G was not available in 27 patients. TNM stage was I in 76 patients, II in 17, III in 23, and IV in 44. RESULTS: Twelve patients developed VTE: 9 had DVT and 3 PE. The primary site of the tumor was located in the pancreas in 9 patients, in the gut in 2, and it was unknown in one patient. Two patients had a functioning tumor. Grading was G1 in 3 patients, G2 in 6, G3 in 2 cases, and not available in one. The TNM stage was IV in 5 patients, III in 2, II in 3, and I in 2. Two patients died during the study period, one of whom died from PE. CONCLUSION: GEP-NEN patients harbor a considerable risk of VTE, particularly high for pancreatic NEN patients, for patients with moderate-poorly differentiated neoplasms, and at an advanced tumor stage.

Safety of liver resection in patients receiving antithrombotic therapy: A systematic review of the literature.

BACKGROUND: Little is unknown about the effect of chronic antithrombotic therapy (ATT) on bleeding complication during or after hepatectomy. In addition, the safety and effectiveness of chemical prevention for venous thromboembolism (VTE) is still controversial. AIM: To clarify the effect of ATT on thromboembolism and bleeding after liver resection. METHODS: Articles published between 2011 and 2020 were searched from Google Scholar and PubMed, and after careful reviewing of all studies, studies concerning ATT and liver resection were included. Data such as study design, type of surgery, type of antithrombotic agents, and surgical outcome were extracted from the studies. RESULTS: Sixteen published articles, including a total of 8300 patients who underwent hepatectomy, were eligible for inclusion in the current review. All studies regarding patients undergoing chronic ATT showed that hepatectomy can be performed safely, and three studies have also shown the safety and efficacy of preoperative continuation of aspirin. Regarding chemical prevention for VTE, some studies have shown a potentially high risk of bleeding complications in patients undergoing chemical thromboprophylaxis; however, its efficacy against VTE has not been shown statistically, especially among Asian patients. CONCLUSION: Hepatectomy in patients with chronic ATT can be performed safely without increasing the incidence of bleeding complications, but the safety and effectiveness of chemical thromboprophylaxis against VTE during liver resection is still controversial, especially in the Asian population. Establishing a clear protocol or guideline requires further research using reliable studies with good design.

Recurrent sustained atrial arrhythmias and thromboembolism in Fontan patients with total cavopulmonary connection.

BACKGROUND: Total cavopulmonary connection (TCPC) is associated with a lower risk of incident atrial arrhythmias as compared to atriopulmonary Fontan, but the risk of recurrent atrial arrhythmias is unknown in this population. The purpose of this study was to determine the incidence and risk factors for recurrent atrial arrhythmias and thromboembolic complications in patients with TCPC. METHODS: This is a retrospective multicenter study conducted by the Alliance for Adult Research in Congenital Cardiology (AARCC), 2000-2018. The inclusion criteria were TCPC patients (age > 15 years) with prior history of atrial arrhythmia. RESULTS: A total of 103 patients (age 26 ± 7 years; male 58 [56%]) met inclusion criteria. The mean age at initial arrhythmia diagnosis was 13 ± 5 years, and atrial arrhythmias were classified as atrial flutter/tachycardia in 85 (83%) and atrial fibrillation in 18 (17%). The median duration of follow-up from the first episode of atrial arrhythmia was 14.9 (12.1-17.3) years, and during this period 64 (62%) patients had recurrent atrial arrhythmias (atrial flutter/tachycardia 51 [80%] and atrial fibrillation 13 [20%]) with annual incidence of 4.4%. Older age was a risk factor for arrhythmia recurrence while the use of a class III anti-arrhythmic drug was associated with a lower risk of recurrent arrhythmias. The incidence of thromboembolic complication was 0.6% per year, and the cumulative incidence was 4% and 7% at 5 and 10 years respectively from the time of first atrial arrhythmia diagnosis. There were no identifiable risk factors for thromboembolic complications in this cohort. CONCLUSIONS: Although TCPC provides superior flow dynamics and lower risk of incident atrial arrhythmias, there is a significant risk of recurrent arrhythmias among TCPC patients with a prior history of atrial arrhythmias. These patients may require more intensive arrhythmia surveillance as compared to other TCPC patients.

Mechanical thrombectomy for occlusion near a ruptured intracranial aneurysm: A case report.

BACKGROUND: While recent randomized clinical trials have shown the efficacy of mechanical thrombectomy for acute large vessel anterior cerebral occlusion, cases in patients with a subarachnoid hemorrhage (SAH) were excluded from the study. CASE DESCRIPTION: A 58-year-old man presented with a SAH as a result of a ruptured middle cerebral artery aneurysm. Coil embolization was performed, and a right intracranial angiography showed remnants of an aneurysmal neck. However, the following angiography also revealed a thromboembolic complication that occurred in the same territory as the ruptured aneurysm. The patient underwent a rescue mechanical thrombectomy under the working projection. We deployed a retrieval stent without covering the aneurysmal neck. The occluded vessel was recanalized without any hemorrhagic complication. Due to minimal intracerebral infarction, the patient had good outcomes. CONCLUSION: Mechanical thrombectomy is a useful option to retrieve a clot from an occluded intracranial vessel located near a ruptured aneurysm. Approaching the clot at the working projection is important to ensure safety in the setting of a ruptured aneurysm.

Impact of age on thromboembolic events in patients with non-valvular atrial fibrillation.

BACKGROUND: Age is a well-established risk factor for thromboembolic events in patients with atrial fibrillation (AF). However, the mechanism underlying the association between age and thromboembolic events in AF remains unknown. METHODS: The prognostic value of age as a risk factor for thromboembolic events was analyzed using data from the Korean National Health Insurance Service (NHIS). In a large-scale single-center registry, cardiac hemodynamic parameters were examined to elucidate the cause of increased risk of thromboembolic events in older patients. RESULTS: NHIS sample cohort data including 5896 patients with AF revealed that the risk of thromboembolic complication differed significantly according to age despite equal CHA2 DS2 -VASc score. In the registry of 2801 patients, age showed significant correlations with left atrium (LA) diameter, LA volume, E/e', pulmonary artery pressure, and LA appendage flow velocity. Older patients had a significantly higher prevalence of spontaneous echocontrast (odds ratio [OR] = 1.030; P < .001). Age (OR = 1.031; P < .001), E/e' (OR = 1.065; P = .004), and LA appendage flow velocity (OR = .988; P = .009) were significant predictors for thromboembolic events in multivariate analyses. In data from the NHIS, CHA2 DS2 -VASc score did not outperform age to predict thromboembolic events. CONCLUSIONS: Age is a significant risk factor for thromboembolic events in patients with AF, and old age is associated with adverse cardiac hemodynamics. This study suggests that older patients with AF are at high risk of thromboembolic events regardless of CHA2 DS2 -VASc score.

Early versus delayed cardioversion: why should we wait?

Introduction: Cardioversion (CV) is the essential component of rhythm control strategy for atrial fibrillation (AF). This review will focus on how the timing of CV affects the efficacy and safety of rhythm control strategy.Areas covered: There are no randomized studies assessing the effect of timing on CV outcome. Based on observational studies, the success of CV of acute (<48 hours) AF is consistently better than the later CV of persistent AF. Early AF recurrences are common, but early timing of CV seems to reduce recurrences. Risk of thromboembolic complications increases with the delay of CV in spite of the use of therapeutic anticoagulation. Clinically significant arrhythmic complications are rare after CV irrespective of procedure timing.Expert opinion: Based on observational studies the optimal timing of CV seems to be at 12-48 h after the onset of arrhythmic symptoms. Before proceeding to CV, the probability of early treatment failure and antiarrhythmic treatment options should be carefully evaluated to avoid the risks of repeated futile CVs. Effective anticoagulation is crucial to prevent thromboembolic complications. The first week after CV is the most vulnerable period in this respect.

Perioperative antithrombotic management of patients who receive direct oral anticoagulants during gastroenterological surgery.

AIM: We investigated the effect of perioperative management of direct oral anticoagulants (DOACs) on bleeding and thromboembolic complications during gastroenterological (GE) surgery. METHODS: A total of 334 patients receiving anticoagulants and undergoing elective GE surgery between 2012 and 2018 were enrolled. The patients were divided into three groups: patients receiving warfarin (WF, n = 231), patients receiving DOACs with heparin bridging (DOAC-HB, n = 34), and patients receiving DOAC without heparin bridging (DOAC-NHB, n = 69). Outcome variables were compared between the groups and the risk factors of postoperative bleeding were assessed using logistic multivariate analysis. RESULTS: No significant differences were observed in background characteristics between the groups. There were similarities between the groups in surgical blood loss (P = .772) and rate of intraoperative transfusion (P = .952). Thromboembolic complications only occurred in two patients in the WF group (0.9%), and no thromboembolism occurred in the DOAC groups. The incidence of major postoperative bleeding was significantly higher in DOAC-HB group than in the other groups (14.7% vs 4.8% vs 1.4%, P = .011). Multivariate analysis showed DOAC with heparin bridging to be the most significant risk factor of major postoperative bleeding (odds ratio = 11.60, P = .028). CONCLUSIONS: Elective GE surgery can be safely performed in patients receiving DOACs without heparin bridging. Perioperative heparin bridging during DOAC interruption is not recommended even for patients undergoing major GE surgery due to increased postoperative bleeding.

Pulmonary vein thrombosis and cerebral infarction after video-assisted thoracic surgery of the left upper lobe: a case series.

BACKGROUND: Pulmonary vein thrombosis (PVT) and cerebral infarction are rare but critical complications after video-assisted thoracic surgery (VATS). CASE PRESENTATION: We experienced two cases of massive middle cerebral artery infarction after VATS for the left upper lobe. Although the precise source of their embolus was never identified, both cases were clinically suspected PVT. Unfortunately, case 2 died because of progressive cerebral herniation. We decided to perform contrast-enhanced computed tomography routinely after VATS for the left upper lobectomy (VATS-LUL) after these cases. Case 3, a 79-year-old female patient, underwent VATS-LUL for lung cancer. She developed PVT in the stump of the left upper pulmonary vein on postoperative day 4. Anti-coagulation therapy was begun immediately and continued for 3 months. She was free of complications 7 months after the operation. CONCLUSION: PVT and cerebral infarction may occur after VATS-LUL. Appropriate postoperative management is required to recognize PVT and to prevent life-threatening stroke.

Procoagulation, hypercoagulation and fibrinolytic "shut down" detected with ClotPro® viscoelastic tests in COVID-19 patients. / Procoagulatio, hypercoagulatio és fibrinolysis "shut down" kimutatása ClotPro® viszkoelasztikus tesztek segítségével COVID-19-betegekben.

INTRODUCTION: International data indicate that arterial, venous and microvascular thrombosis or disseminated intravascular coagulation occur in more than 30% of hospitalized patients with COVID-19. This condition is characterized by high levels of D-dimer and fibrinogen, prolonged prothrombin time and activated partial thromboplastin time. METHOD: Blood samples from three COVID-19 patients treated in a Hungarian intensive care unit were collected and analyzed with ClotPro® tests. EX-tests, IN-test, FIB-tests, RVV-tests, and TPA-tests were performed. The results were interpreted with respect to the clinical condition of the patients. RESULTS: Procoagulation, hypercoagulation and either fibrinolysis or a "shut down" phenomenon of the fibrinolytic process were found with ClotPro®. The ClotPro® parameters were consistent with the conventional coagulation tests and corresponded with the criteria of non-overt disseminated intravascular coagulation. CONCLUSION: These findings encourage further investigations to elucidate the underlying pathophysiology of thromboembolic events in COVID-19 patients and may support the introduction of full dose anticoagulation with or without antiplatelet therapy. Interventional clinical trials may be helpful in defining the appropriate drug(s), for this purpose, the algorithms of administration, and the optimal duration of therapy. At present, the authorization of a clinical trial that attempts to answer these questions is in progress. Orv Hetil. 2020; 161(22): 899-907.

Treatment of acute thromboembolic complication after stent-assisted coil embolization of ruptured intracranial aneurysm: a case report.

A 45-year-old Chinese man presented with acute severe headache for 2 days. He was diagnosed as subarachnoid hemorrhage. Head CT and subsequent head digital subtraction angiography (DSA) showed left internal carotid artery (ICA) aneurysm in the supraclinoid segment. Stent-assisted coil embolization of aneurysm was performed. Three hours after the surgery, the patient was found to be drowsy and with paralysis of the right limb and slurred speech. Urgent head CT examination ruled out acute hemorrhage; however, DSA showed acute thrombosis in the left ICA between the branches of the ophthalmic artery and middle cerebral artery, which was probably from an acute in-stent thrombosis. Urokinase (100,000 units) was given through a micro-tube but failed to dissolve the thrombus; thus, stent embolectomy was performed, which successfully removed the thrombus. Repeat angiography showed that the left ICA was completely recanalized. Postoperatively, the patient regained consciousness and was well-limbed and fluent in speech. No neurological symptoms or signs were found at 6-, 12-, and 24-month follow-up.