Hemodialysis with a dialyzer loaded with argatroban may be performed in vivo without a systemic anticoagulant.

BACKGROUND/AIMS: Anticoagulation in hemodialysis (HD) patients at high risk of bleeding remains an intractable problem. Simulating endothelial cells by releasing anticoagulant on the membrane may be a promising alternative. METHODS: We modified a polyacrylonitrile (PAN) dialyzer by loading argatroban into its membrane and verified its anticoagulation efficiency and its influence on coagulation markers such as activated partial thromboplastin time (aPTT), D-dimer and thrombin-antithrombin complex (TAT) in an animal HD model. RESULTS: All HD sessions with the argatroban dialyzer were completed successfully with either no or minimal fiber clotting. D-dimer was lower in the argatroban group than in the PAN group; TAT and aPTT values were similar in the two groups, which suggests better anticoagulation and a similar influence on the coagulation system. CONCLUSION: HD with the argatroban dialyzer is feasible, safe and simple, and could be used in patients at high risk of bleeding.

In vitro effects of detergent sclerosants on clot formation and fibrinolysis.

OBJECTIVE: To investigate the in vitro effects of detergent sclerosants sodium tetradecyl sulphate (STS) and polidocanol (POL) on clot formation and lysis. MATERIALS AND METHODS: clot kinetics were assessed in whole blood by thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®). Fibrinogen was measured by the Clauss method in plasma and factor XIII (FXIII) by enzyme-linked immunosorbent assay (ELISA). Turbidity measurements were used to assess clot lysis in plasma, and fibrinolysis in non-cross-linked and cross-linked fibrin. D-dimer was measured by VIDAS®, STA®Liatest® and AxSYM® assays. RESULTS: Strong clots were formed at low sclerosant concentrations (0.075-0.1%). At midrange concentrations (0.15% STS, 0.15-0.3% POL), both agents inhibited the contribution of platelets to clot firmness and formed weak clots prone to lysis. At higher concentrations (STS ≥ 0.3% and POL ≥ 0.6%), clot formation was inhibited. STS destroyed FXIII at ≥ 0.15% and fibrinogen at ≥ 0.6%. Neither sclerosant had a significant effect on cross-linked fibrin, but STS had a lytic effect on non-cross-linked fibrin. STS caused an artefactual elevation of D-dimer in the VIDAS® assay when fibrinogen was present. CONCLUSION: Detergent sclerosants demonstrated a trimodal effect on clot formation, initiating strong clots at low concentrations, weak clots at midrange concentrations and preventing clot formation at higher concentrations. Neither agent had fibrinolytic activity.

[Clinical usefulness of Nephral ST dialyzers in hemodialyzed patients with increased risk of bleeding]. / Przydatnosc kliniczna dializatorów Nephral ST u chorych hemodializowanych z ryzykiem krwawienia.

Hemodialyzed patients with increased risk of bleeding can be dialyzed according to a method of limited anticoagulant use including saline flush technique, regional citrate anticoagulation, regional heparinization or use of membranes with low thrombogenic properties. Methods that limit anticoagulation use are not completely effective, increase work load for the dialysis team and create a risk of complications. The aim of the study was to evaluate the clinical usefulness of Nephral ST dialyzers with poli-acrylonitrile membranes treated with polyethylenimine binding heparin in hemodialyzed patients with increased risk of bleeding. In 12 patients with increased bleeding risk, 121 hemodialyzed sessions were performed utilizing Nephral ST dialyzers. Heparin was not administered during the procedure. Degree of clotting of the dialyzer and the venous drip chamber was evaluated using a 4-degree visual scale. Platelet count, partial activation time of thromboplastine (APTT), thrombin time (TT), antithrombin III, as well as d-dimer concentrations were measured before dialysis and after 15, 120 and 240 minutes of procedure. No complications of massive clotting necessitating premature termination of dialysis was noted. In most sessions trace or small clotting was observed in the dialyzers and drip chambers. No significant differences in platelet count and AT III levels were measured. Increased TT and APTT after 15 minutes of dialysis were observed, which was probably due to release of small amounts of dialyzer membrane heparin. After 120 and 240 minutes these values returned to normal ranges. These observations along with increased d-dimers after 240 minutes suggested an increased risk of clotting during evaluated sessions. Application of Nephral ST dialyzers permits for heparin-free dialysis procedure in patients with increased risk of bleeding.

Clinical application of a new latex photometric immunoassay reagent, LPIA-GENESIS D-dimer, and its performance in patient-derived plasma samples.

INTRODUCTION: We previously reported an antibody MIF-220 that recognizes a specific structure induced on the surface of thrombin-activated E-domain of one fibrin molecule bound with the D-domains of other fibrinogen/fibrin molecules. Utilizing MIF-220, we produced a test kit for cross-linked fibrin degradation products (XDP), LPIA-GENESIS D-dimer (LG-DD), and evaluated basic performance characteristics for clinical application. We then attempted to apply LG-DD to see its eligibility in clinical plasma samples. METHOD: The characteristic performances requested for clinical use were studied including limit of quantitation, within-run imprecision, day-to-day imprecision, antigen excess, interference study, and method comparison with LPIAACE-Ddimer (ACE-DD) available on the market. RESULTS: The performance characteristics were all satisfactory. Extraordinarily high concentrations of XDP are occasionally obtained by ACE-DD in samples with collection problems, but not by LG-DD, indicating that a certain XDP species present in the former was not measured by LG-DD. Structural studies suggested that the "B-b" set of polymerization sites must be involved as well in the maintenance of cross-linked fibrin in vivo. CONCLUSION: LG-DD was able to measure a wide range of XDP, that is, 0.20-35.0 µg FEU/mL that covers the levels of XDP in most of the clinical samples. LG-DD was found to almost avoid false-positive results noticed in samples as mentioned above, and this feature seems to be preferable to established kits for the measurement of XDP.

Salivary D-dimer in pigs: Validation of an automated assay and changes after acute stress.

D-dimer is a peptide found in serum and is derived from the degradation of blood clots. Even though it has been analysed in human saliva, D-dimer has not been previously evaluated in the saliva of any veterinary species, and its source and role remain unknown. The objectives of this research were firstly, to validate the use of an automated method for the measurement of D-dimer in porcine saliva, and secondly, to evaluate whether D-dimer concentration changes in pig saliva after an acute stress stimulus. For this purpose, a complete analytical validation of a commercially-available immunoturbidimetric assay was carried out. In addition, an experimental acute stress model was induced in 11 pigs based on a technique involving restraint by nose-snare immobilisation for 1 min. Saliva samples were subsequently collected at different times and D-dimer, salivary alpha-amylase (sAA) and cortisol were assessed in order to evaluate changes in its concentrations after the stress induction. The D-dimer automated assay showed adequate reproducibility and sensitivity, with coefficients of variation below 10% and a limit of quantification of 0.167 µg/mL fibrinogen equivalent units (FEU). It also showed a high accuracy, determined by linearity under dilution and recovery tests. In the stress model, a significant increase (P < 0.05) in salivary D-dimer 15 min after the stress stimulus and a positive correlation between D-dimer and sAA (r = 0.51; P < 0.001) were observed. These results indicate that D-dimer can be measured in porcine saliva with an automated method and suggest that its concentration can be influenced by stressful conditions.

Overcommitment but not effort-reward imbalance relates to stress-induced coagulation changes in teachers.

BACKGROUND: Stress-related hypercoagulability might link job stress with atherosclerosis. PURPOSE: This paper aims to study whether overcommitment, effort-reward imbalance, and the overcommitment by effort-reward imbalance interaction relate to an exaggerated procoagulant stress response. METHODS: We assessed job stress in 52 healthy teachers (49 +/- 8 years, 63% women) at study entry and, after a mean follow-up of 21 +/- 4 months, when they underwent an acute psychosocial stressor and had coagulation measures determined in plasma. In order to increase the reliability of job stress measures, entry and follow-up scores of overcommitment and of effort-reward imbalance were added up to total scores. RESULTS: During recovery from stress, elevated overcommitment correlated with D-dimer increase and with smaller fibrinogen decrease. In contrast, overcommitment was not associated with coagulation changes from pre-stress to immediately post-stress. Effort-reward imbalance and the interaction between overcommitment and effort-reward imbalance did not correlate with stress-induced changes in coagulation measures. CONCLUSIONS: Overcommitment predicted acute stress-induced hypercoagulability, particularly during the recovery period.

Impact of non-di-(2-ethylhexyl)phthalate cardiopulmonary bypass tubes on inflammatory cytokines and coagulation-fibrinolysis systems during cardiopulmonary bypass.

Di-(2-ethylhexyl)phthalate (DEHP), an excellent plasticizer for poly(vinyl chloride) (PVC), is a known endocrine-disrupting chemical. This study was designed to investigate whether a new non-DEHP bilayer tube reduced the release of DEHP, suppressed inflammatory cytokines, and altered coagulation-fibrinolysis systems. Sixteen patients undergoing coronary artery bypass grafting (CABG) were randomly assigned to the non-DEHP bilayer group (group B, n = 8), or the noncoated PVC group (group N, n = 8). The level of DEHP in the blood was measured before and after cardiopulmonary bypass (CPB). The levels of interleukin-6 (IL-6), D-dimer, and thrombin-antithrombin complex (TAT) were also measured at six points during and after CPB. DEHP was significantly lower in group B (472 +/- 141 ng/ml) after CPB compared with group N (2094 +/- 1046 ng/ml). The IL-6 level was significantly lower in group B (151 +/- 131 pg/ml) than group N (206 +/- 224 pg/ml) 180 min after protamine administration. The D-dimer level was significantly lower in group B 60 min after protamine administration (6.2 +/- 2.4 microg/ml in group B vs 10.4 +/- 4.5 microg/ml in group N) and 180 min after protamine administration (4.4 +/- 0.7 microg/ml in group B vs 7.3 +/- 2.7 microg/ml in group N). Group B had a tendency toward reduced postoperative bleeding compared with group N at any time. The bilayer tube was superior to the noncoated tube in terms of the inhibition of DEHP release, inflammatory cytokines, and the fibrinolysis system.

[Hemocompatibility of bovine pericardium with additional sodium bisulfite treatment].

OBJECTIVE: To evaluate the hemocompatibility of glutaraldehyde (GA)-tanned bovine pericardium additionally treated by sodium bisulfite (SOB) solution. METHODS: The hemocompatibility of GA-tanned bovine pericardium treated by SOB solution is evaluated by using dynamic clotting time test, blood platelet adhension test, D-dimeride determination, and complement activation test. The GA-tanned bovine pericardium was used as control. RESULTS: The curve of absorbance-clotting time of two kinds of bovine pericardium was similar in dynamic clotting time test. There was no significant difference between SOB-treated and control groups in blood platelet adhension test. The D-dimeride contents of all bioprostheses were at normal level, and the D-dimeride content of GA-tanned bovine pericardium treated by SOB solution was significantly lower than that of control group (P < 0.05). In complement activation test, the level of complement C3a in SOB-treated group was significantly lower than that in control group (P < 0.05). CONCLUSION: GA-tanned bovine pericardium treated by SOB solution meets the demands of cardiac interstitial implanted materials in hemocompatibility.

Local and Systemic Changes Associated with Long-term, Percutaneous, Static Implantation of Titanium Alloys in Rhesus Macaques (Macaca mulatta).

Metal alloys are frequently used as implant materials in veterinary medicine. Recent studies suggest that many alloys induce both local and systemic inflammatory responses. In this study, 37 rhesus macaques with long-term skull-anchored percutaneous titanium alloy implants (duration, 0 to 14 y) were evaluated for changes in their hematology, coagulation, and serum chemistry profiles. Negative controls (n = 28) did not have implants. Macaques with implants had higher plasma D-dimer and lower antithrombin III concentrations than nonimplanted animals. In addition, animals with implants had higher globulin and lower albumin and calcium concentrations compared with nonimplanted macaques. Many of these changes were positively correlated with duration of implantation and the number of implants. Chronic bacterial infection of the skin was present around many of the implant sites and within deeper tissues. Representative histopathology around the implant site of 2 macaques revealed chronic suppurative to pyogranulomatous inflammation extending from the skin to the dura mater. X-ray fluorescence microscopy of tissue biopsies from the implant site of the same 2 animals revealed significantly higher levels of free metal ions in the tissue, including titanium and iron. The higher levels of free metal ions persisted in the tissues for as long as 6 mo after explantation. These results suggest that long-term skull-anchored percutaneous titanium alloy implants can be associated with localized inflammation, chronic infection, and leaching of metal ions into local tissues.

[Pulmonary Embolism Despite Rivaroxaban in an Obese Patient]. / Pulmonalembolie trotz Rivaroxaban bei einer adipösen Patientin.

Introduction Rivaroxaban, an oral factor Xa inhibitor, is approved for therapy of venous thromboembolism. It is unclear whether the standard dose for patients with a body mass index (BMI) > 40 kg/m2 is sufficient. History The 45-year-old patient was admitted because of increasing respiratory distress. She had a history of pulmonary embolism 30 months before the admission, a factor V Leiden mutation and several hospitalisations due to dermatomycoses. The patient briefly took phenprocoumon which was changed to 20 mg rivaroxaban due to a lack of adherence. Six months before admission, the patient paused the rivaroxaban therapy because of dental surgery and suffered a recurrent pulmonary embolism. Findings and Diagnosis The patient presented with increasing difficulty of breathing, morbid obesity with a BMI of 59.3 kg/m2 and intertrigo of the lower extremities. The ECG showed a right axis deviation, a pulmonary P-wave and an incomplete right bundle branch block. Computed tomography showed pulmonary embolisms of the left lower lobe. The pulmonary artery was dilated, and the right atrium was enlarged. Venous thrombosis of the lower limb could not be certainly ruled out. The D-dimer was elevated with 5.895 mg/L (normal value up to 169 mg/L) and NT-pro-BNP was elevated at 5.580 ng/L (normal value up to 0.5 ng/L). Sixteen hours after the onset of symptoms, 22 hours after the last dose, the serum rivaroxaban level was 137 ng/ml. According to manufacturers, the therapeutic range of rivaroxaban after 2 - 4 hours is 22 - 535 ng/ml, and after 24 hours 6 - 239 ng/ml. Therapy and course After initiation of a therapy with low-molecular weight heparin and subsequent oral anticoagulation with phenprocoumon, the symptoms decreased. Conclusions It is highly probable that the pulmonary embolism occurred at a time when the rivaroxaban level was in the therapeutic range. Since there are only few data about safety and efficacy of rivaroxaban and other non-vitamin K-oral anticoagulants (NOACs) in severely obese patients, the recommendations of the "International Society for Thrombosis and Haemostasis" should be followed: Rivaroxaban and other NOACs should not be used in patients with a BMI > 40 kg/m2 or weight > 120 kg, since only few data on this patient group are available. If NOACs are necessary in these patients, serum concentrations of NOACs should be measured.

Fibrin self-assembly is adapted to oxidation.

Fibrinogen is extremely susceptible to attack by reactive oxygen species (ROS). Having been suffered an oxidative modification, the fibrinogen molecules, now with altered spatial structure and function of fibrin network, affect hemostasis differently. However, the potential effects of the oxidative stress on the early stages of the fibrin self-assembly process remain unexplored. To clarify the damaging influence of ROS on the knob 'A': hole 'a' and the D:D interactions, the both are operating on the early stages of the fibrin polymerization, we have used a novel approach based on exploration of FXIIIa-mediated self-assembly of the cross-linked fibrin oligomers dissolved in the moderately concentrated urea solutions. The oligomers were composed of monomeric desA fibrin molecules created by cleaving the fibrinopeptides A off the fibrinogen molecules with a thrombin-like enzyme, reptilase. According to the UV-absorbance and fluorescence measurements data, the employed low ozone/fibrinogen ratios have induced only a slight fibrinogen oxidative modification that was accompanied by modest chemical transformations of the aromatic amino acid residues of the protein. Else, a slight consumption of the accessible tyrosine residues has been observed due to intermolecular dityrosine cross-links formation. The set of experimental data gathered with the aid of electrophoresis, elastic light scattering and analytical centrifugation has clearly witnessed that the oxidation can serve as an effective promoter for the observed enhanced self-assembly of the covalently cross-linked oligomers. At urea concentration of 1.20M, the pristine and oxidized fibrin oligomers were found to comprise a heterogeneous set of the double-stranded protofibrils that are cross-linked only by γ-γ dimers and the fibers consisting on average of four strands that are additionally linked by α polymers. The amounts of the oxidized protofibrils and the fibers accumulated in the system were higher than those of the non-oxidized counterparts. Moreover, the γ and α polypeptide chains of the oxidized molecules were more readily crosslinked by the FXIIIa. Upon increasing the urea solution concentration to 4.20M, the cross-linked double-stranded desA fibrin protofibrils have dissociated into the single-stranded fibrin oligomers, whereas the fibers dissociated into both the double-stranded desA fibrin oligomers, the structural integrity of the latter being maintained by means of the intermolecular α polymers, and the single-stranded fibrin oligomers cross-linked only by γ-γ dimers. The data we have obtained in this study indicate that the FXIIIa-mediated process of assembling the cross-linked protofibrils and the fibers constructed from the oxidized monomeric fibrin molecules was facilitated due to the strengthening of D:D interactions. The findings infer that the enhanced longitudinal D:D interactions become more essential in the assembly of soluble protofibrils when the interactions knobs 'A': holes 'a' are injured by oxidation. The new experimental findings presented here could be of help for elucidating the essential adaptive molecular mechanisms capable of mitigating the detrimental action of ROS in the oxidatively damaged fibrin self-assemblage processes.

Evaluation of the biphasic calcium composite (BCC), a novel bone cement, in a minipig model of pulmonary embolism.

Polymethylmethacrylate (PMMA) bone cement, which is used as a filler material in vertebroplasty, is one of the major sources of pulmonary embolism in patients who have undergone vertebroplasty. In the present study, we established and evaluated two animal models of pulmonary embolism by injecting PMMA or biphasic calcium composite (BCC) bone cement with a negative surface charge. A total of 12 adults and healthy Wuzhishan minipigs were randomly divided into two groups, the PMMA and BBC groups, which received injection of PMMA bone cement and BBC bone cement with a negative surface charge in the circulation system through the pulmonary trunk, respectively, to construct animal models of pulmonary embolism. The hemodynamics, arterial blood gas, and plasma coagulation were compared between these two groups. In addition, morphological changes of the lung were examined using three-dimensional computed tomography. The results showed that both PMMA and BCC injections induced pulmonary embolisms in minipigs. Compared to the PMMA group, the BCC group exhibited significantly lower levels of arterial pressure, pulmonary artery pressure, blood oxygen pressure, blood carbon dioxide pressure, blood bicarbonate, base excess, antithrombin III and D-dimer. In conclusion, BCC bone cement with a negative surface charge is a promising filler material for vertebroplasty.

Influence of fibrinogen on fibrin polymerization. Ultracentrifugation studies.

During the transformation of fibrinogen to fibrin, excess fibrinogen suppresses further polymerization of fibrin, thereby enabling the nascent fibrin to be transported in a soluble form in blood. The question of possible complex formation between fibrin and fibrinogen was addressed by analyzing fibrin/fibrinogen (1:20, mol/mol) mixtures in the presence of calcium ions in stable linear sucrose density gradients by ultracentrifugation at 37 degrees C. During the period of ultracentrifugation in independent experiments, 40% of desAA-fibrin and 30% of desAABB-fibrin, respectively, precipitated without the participation of fibrinogen. The desAABB-fibrin, recovered in the gradient fractions, appeared as high-molecular-weight polymers (22 S), whereas the recovered desAA-fibrin exhibited only a slight increase in molecular weight (9 S) compared to fibrinogen (8 S). In contrast to this finding, both types of fibrin were totally recovered in gradient fractions provided that fibrinogen was present in the gradient at a uniform concentration of 2 mg/ml. In addition, the presence of fibrinogen but not human serum albumin reduced the size of desAABB-fibrin polymers (17 S). However, stable fibrin-fibrinogen complexes could not be demonstrated, since cosedimentation of differently labelled desAABB-fibrin and fibrinogen was not detectable. These studies suggest a specific but weak interaction of the solubilizing fibrinogen with the soluble fibrin polymers as demonstrated by a rapid exchange of both macromolecules.

Novel bioresorbable stent coating for drug release in congenital heart disease applications.

A novel double opposed helical poly-l-lactic acid (PLLA) bioresorbable stent has been designed for use in pediatrics. The aim was to test the PLLA stent biocompatibility. The PLLA stent was immersed into whole pig's blood in a closed loop circuit then fibrin and platelet association was assessed via enzyme-linked immunosorbent assay. D-Dimer was valued at 0.2 ± 0.002 ng/mL and P-selectin 0.43 ± 00.01 ng/mL indicating limited association of fibrin and platelets on the stent. To improve biocompatibility by targeting inflammatory cells, dexamethasone was incorporated on PLLA fibers with two coating methods. Both coatings were poly(l-lactide-co-glycolide) acid (PLGA) but one was made porous with sucrose while the other remained nonporous. There was no change in mechanical properties of the fiber with either coating of PLGA polymer. The total amount of dexamethasone released was then determined for each coating. The cumulative drug release for the porous fiber was significantly higher (∼100%) over 8 weeks than the nonporous fiber (40%). Surface examination of the fiber with scanning electron microscopy showed more surface microfracturing in coatings that contain pores. The biocompatibility of this novel stent was demonstrated. Mechanical properties of the fiber were not altered by coating with PLGA polymer. Anti-inflammatory drug release was optimized using a porous PLGA polymer.

Removal of low density lipoprotein from blood plasma using cross-linked, sulfated polyvinylalcohol.

The properties of a new synthetic LDL binding material, consisting of fragments of loosely crosslinked hydrogel, based on sulfated polyvinylalcohol are described. When incubated with 20 times its volume of plasma, this material binds up to 95% of the LDL, even from plasma with severely elevated LDL cholesterol levels (up to 20 mM). In addition a cholesterol-rich subfraction of VLDL is bound but HDL is not bound. After about 10 min binder/plasma contact the LDL removal is complete and no other additives are required. LDL binding capacity is dependent on the average binder particle size, indicating a restricted penetration of LDL particles into the binder matrix.

The interaction of fibronectin (fn) with native, polymeric collagen (collagen fibres): comparison with von Willebrand factor (vWf)-binding by collagen.

The binding of fn to collagen (type I) fibres has been found to resemble that of vWf in the following respects: Binding is rapid, specific, saturable, similar at 4 and 37 degrees C, and reduced by increasing ionic strength. Binding is not inhibited by native, monomeric collagen, suggesting a multivalent mechanism of interaction. Binding of fn occurs to a variety of collagen fragments (after their renaturation and polymerization), including, for example, the collagenase-derived TCA and TCB 3/4 and 1/4 molecular fragments and the peptides alpha 1(I)CB3, 6b, 7 and 8 obtained by cleavage with cyanogen bromide (CB), suggesting a wide distribution of binding sites on the native collagen molecule. As judged by the effect of heat-treatment, the native conformation of fn is required. Chemical modification indicates the involvement of arginyl residues in collagen and carboxyl groups in fn. However, fn and vWf did not compete with one another in binding to collagen, suggesting the participation of different collagen arginyl residues in the two interactions. Fn-binding differed from that of vWf in that the former was inhibited by denatured monomeric collagen (gelatin). Fn-binding was also inhibited by the fragment TCA in denatured form. The inhibitory activity was lost after chemical modification of arginyl residues in gelatin. Our results suggest that fn binding to collagen fibres and gelatin involves the same widely-distributed spectrum of binding sites.

D-dimer test and diagnosis of deep vein thrombosis: a comparative study of 7 assays.

The current D-Dimer ELISA methods provide high sensitivity and negative predictive value for the diagnosis of deep vein thrombosis but these methods are not suitable for emergency or for individual determination. We have evaluated the performance of 3 newly available fast D-Dimer assays (Vidas D-Di, BioMérieux; Instant IA D-Di, Stago; Nycocard D-Dimer, Nycomed) in comparison with 3 classic ELISA methods (Stago, Organon, Behring) and a Latex agglutination technique (Stago). One-hundred-and-seventy-one patients suspected of presenting a first episode of deep vein thrombosis were investigated. A deep vein thrombosis was detected in 75 patients (43.8%) by ultrasonic duplex scanning of the lower limbs; in 11 of them the thrombi were distal and very limited in size (< 2 cm). We compared the performance of the tests by calculating their sensitivity, specificity, positive and negative predictive value for different cut-off levels and by calculating the area under ROC curves. The concordance of the different methods was evaluated by calculating the kappa coefficient. The performances of the 3 classic ELISA and of the Vidas D-Di were comparable and kappa coefficients indicated a good concordance between the results provided by these assays. Their sensitivity slightly declined for detection of the very small thrombi. Instant IA D-Di had a non-significantly lower sensitivity and negative predictive value than the 4 previous assays; however its performance was excellent for out-patients. As expected, the Latex assay had too low a sensitivity and negative predictive value to be recommended. In our hands, Nycocard D-Dimer also exhibited low sensitivity and negative predictive value, which were significantly improved when the plasma samples were tested by the manufacturer. Thus significant progress has been made, allowing clinical studies to be planned to compare the safety and cost-effectiveness of D-Dimer strategy to those of the conventional methods for the diagnosis of venous thrombosis.

Expression of fibrinolysis activators and their inhibitor in neointima of polyester vascular grafts.

The aim of the study was to evaluate dynamic changes in the expression of fibrinolytic system components in neointima forming in polyester vascular grafts. The study was carried out on 18 mongrel dogs divided into three groups, that underwent replacement of abdominal aorta with a polyester double velour prosthesis. Grafts were removed at 1, 4 and 12 months. The specimens were fixed according to AMeX method. Immunohistochemical labeling for von Willebrand factor (vWf), tissue plasminogen activator (t-PA), urokinase (u-PA), its receptor (u-PAR), plasminogen activator inhibitor type 1 (PAI-1) and D-dimer (DD) was performed. Increasing intensity of vWf expression on the graft luminal surface was found in successive periods of the study. A light positive t-PA and u-PA staining was shown in neointima at 1 month and its intensity was significantly increased at 4 and 12 months. Expression of u-PAR appeared at 4 months. A light positive PAI-1 and DD staining was demonstrated in neointima in all periods of the study. The results demonstrated increasing expression of fibrinolysis activators in neointima of polyester vascular grafts. Intensive expression of plasminogen activators, when compared to their inhibitor may reduce thrombotic properties of graft neointima particularly in the late period after prosthesis implantation.

Coagulofibrinolysis during heparin-coated cardiopulmonary bypass with reduced heparinization.

BACKGROUND: We examined the safety of reduced systemic heparinization during heparin-coated cardiopulmonary bypass by measuring coagulofibrinolitic indices, including fibrinopeptide A, which directly reflects fibrinogenesis. METHODS: Twenty-four patients who had elective cardiac operations were perfused using a circuit coated with covalently bonded heparin. Twelve patients received 300 U/kg of heparin and the remaining 12 patients received 150 U/kg. Blood was obtained for the measurement of thrombin-antithrombin III complexes, fibrinopeptide A, plasmin-alpha 2 plasmin inhibitor complexes, and D-dimer preoperatively; after heparin administration; 10, 60, and 90 minutes after the start of bypass; after protamine administration; and 1, 3, 6, 12, and 24 hours after the end of bypass. RESULTS: Preoperative, intraoperative, and postoperative variables including postoperative bleeding were not significantly different between the two groups. Further, there were no complications in either group. No significant differences between the two groups were noted for any hematologic index at any time point. CONCLUSIONS: Reduced systemic heparinization combined with a heparin-coated cardiopulmonary bypass circuit is biochemically and clinically safe but does not reduce postoperative bleeding.

Polymerization of fibrinogen-derived fragment X and subsequent rearrangement of fibers.

Polymerization of purified fragment X preparations, obtained from a late stage 2 plasmin digest of fibrinogen, was studied by turbidimetry and electron microscopy. The thrombin-induced polymerization of fragment X caused a rapid increase in turbidity followed by a slow decrease. The initial turbidity increase of fragment X polymers was considerably greater than that of normal fibrin. Electron microscopy carried out at different time points in the reaction revealed that initially there was a great deal of lateral aggregation of fragment X fibers. At later times, electron microscopy showed that there was more dispersal or disruption of the fibers, corresponding to the decrease in turbidity. The slow decrease in turbidity was apparently caused by the rearrangement and/or splitting apart of fragment X fibers, starting from a state similar to a very coarse clot, with much aggregation of fibers, to a delicate meshwork, similar to a fine clot. These changes in clot and fiber structure may result from cleavages partly in the carboxy-terminal region of the gamma chains and the amino-terminal region of the B beta chain of fragment X or the influence of other non-clottable fragments present in these preparations.