Part 1: Management of Antithrombotic Medications in Dermatologic Surgery.

Perioperative management of antithrombotic agents requires practical and medical considerations. Discontinuing antithrombotic therapies increases the risk of thrombotic adverse events including cerebrovascular accidents, myocardial infarction, pulmonary embolism, deep vein thrombosis, and retinal artery occlusion. Conversely, continuation of antithrombotic therapy during surgical procedures has associated bleeding risks. Currently, no guidelines exist regarding management of antithrombotic agents in the perioperative period for cutaneous surgeries and practice differs by surgeon. Here, we review the data on antithrombotic medications in patients undergoing cutaneous surgery including medication-specific surgical and postoperative bleeding risk if the medications are continued, and thromboembolic risk if the medications are interrupted. Specifically, we focus on vitamin K antagonist (VKA) (warfarin), direct-acting oral anticoagulants (DOAC) (rivaroxaban, apixaban, edoxaban, dabigatran), antiplatelet medications (aspirin, clopidogrel, prasugrel, ticagrelor, dipyridamole), unfractionated heparin, low molecular weight heparin (enoxaparin and dalteparin), fondaparinux, bruton tyrosine kinase inhibitors (BTKi) (ibrutinib, acalabrutinib), and dietary supplements (i.e., garlic, ginger, gingko).

Heparin Loading Dose in Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation.

OBJECTIVE: To study the differences in hemorrhagic and embolic complications among extracorporeal cardiopulmonary resuscitation (ECPR) patients who received and did not receive a loading dose of heparin. DESIGN: This study is a controlled before-after monocentric retrospective study. SETTING: The emergency department of the Aerospace Center Hospital (ASCH). PARTICIPANTS: The authors studied a total of 28 patients who, after a cardiac arrest, underwent ECPR in the emergency department of the ASCH from January 2018 to May 2022. INTERVENTIONS: The authors compared the hemorrhagic and embolic complications and prognosis of the 2 groups based on whether they received a loading dose of heparin anticoagulation therapy before catheterization (a loading-dose group and a non-loading dose- group). MEASUREMENTS AND MAIN RESULTS: There were 12 patients in the loading-dose group and 16 in the nonloading-dose group. There was no statistically significant difference in age, sex, underlying diseases, causes of cardiac arrest, and hypoperfusion time between the 2 groups. The incidence of hemorrhagic complications was 75% in the loading-dose group and 67.5% in the nonloading-dose group. The difference between the 2 groups was not statistically significant (p > 0.05). The incidence of life-threatening massive hemorrhage in the loading-dose group was 50%, and in the nonloading-dose group, it was 12.5%. The difference between the 2 groups was statistically significant (p = 0.03). The incidence of embolic complications in the loading-dose group and nonloading-dose group was 8.3% and 12.5%, respectively, and the difference between the 2 groups was not statistically significant (p > 0.05). The survival rates of the 2 groups were 8.3% v 18.8%, respectively, and the difference between the 2 groups was not statistically significant (p > 0.05). CONCLUSION: In conclusion, in the authors' study of patients undergoing ECPR, administering a loading dose of heparin was associated with an increased risk of early fatal hemorrhage. However, stopping this loading dose did not raise the risk of embolic complications. It also did not lower the risk of total hemorrhage and transfusion.

Perioperative continuation or ultra-early resumption of antithrombotics in elective neurosurgical cranial procedures.

OBJECTIVE: Discontinuation of antithrombotics (AT) prior to elective cranial procedures is common practice, despite the higher risk of thromboembolic complications in these patients. The aim of this study was to investigate the risks and benefits of a new perioperative management protocol of continuation or ultra-early AT resumption in elective cranial procedures. METHODS: This study was an analysis of a prospectively collected cohort of patients undergoing elective cranial surgery with (AT group) and without (control group) AT. For extraaxial or shunt surgeries, acetylsalicylic acid (ASA) was continued perioperatively. For intraaxial pathologies, ASA was discontinued 2 days before surgery and resumed on postoperative day 3. All other AT were discontinued according to their pharmacokinetics, and resumed on postoperative day 3 after unremarkable postoperative imaging. Additionally, the authors performed a retrospective analysis of patients with AT who underwent surgery before implementation of this new AT management protocol (historical AT group). Primary and secondary outcomes were the incidence of hemorrhagic and thromboembolic complications within 3 months after surgery. RESULTS: Outcomes of 312 patients were analyzed (83 [27%] in the AT group, 106 [34%] in the control group, and 123 [39%] in the historical AT group). For all 3 patient groups, the most common type of surgery was craniotomy for intraaxial tumors (14 [17%] in the AT group, 28 [26%] in the control group, and 60 [49%] in the historical AT group). The most commonly used AT were ASA (38 [46%] in the AT group and 78 [63%] in the historical AT group), followed by non-vitamin K oral anticoagulants (32 [39%] in the AT group and 18 [15%] in the historical AT group). The total perioperative discontinuation time in the AT group was significantly shorter than in the historical AT group (median of 4 vs 16 days; p < 0.001). The rate of hemorrhagic complications was 4% (95% CI 1-10) (n = 3/83) in the AT group, 6% (95% CI 2-12) (n = 6/106) in the control group, and 7% (95% CI 3-13) (n = 9/123) in the historical AT group (p = 0.5). The rate of thromboembolic complications was 5% (95% CI 1-12) (n = 4/82) in the AT group, 8% (95% CI 3-15) (n = 8/104) in the control group, and 7% (95% CI 3-13) (n = 8/120) in the historical AT group (p = 0.7). CONCLUSIONS: The presented perioperative management protocol of continuation or ultra-early resumption of AT in elective cranial procedures does not seem to increase the hemorrhagic risk. Moreover, it appears to potentially protect patients from thromboembolic complications.

Early thrombotic and hemorrhagic complications associated with a risk-adjusted postoperative anticoagulation protocol after pediatric liver transplantation.

BACKGROUND: Systemic anticoagulation after pediatric liver transplantation (pLT) is believed to reduce the incidence of vascular thrombosis, but it may also cause an increase in hemorrhagic complications. PROCEDURE: A 5-year retrospective review of pLT done at our institution was performed (2014-2018). The occurrence of early hemorrhagic and thrombotic complications was compared when using low-dose or high-dose anticoagulation after transplant (p < .05 considered significant). RESULTS: Sixty-nine patients received 73 transplants during the study period. Median age at transplant was 2.3 years (40 days to 18.5 years). Low-dose anticoagulation was utilized in 71% cases. Additionally, six patients were converted from low-dose to high-dose anticoagulation because of a thrombotic event or concerns for suboptimal vascular inflow. Postoperative anticoagulation was discontinued in 18 occurrences due to bleeding (low dose 19%, high dose 47% vs. low dose to high dose 17%, p = .085). Surgical take back for bleeding occurred in 17 occasions (low dose 13.5%, high dose 53% vs. low dose to high dose 33%, p = .005). The overall incidence of hepatic artery thrombosis (HAT) and portal vein thrombosis were each 5.5%, respectively. While patient survival was not statistically different between groups, graft survival was significantly lower in the high-dose group (low dose 93%, high dose 73% vs. low dose to high dose 100%, p = .046). However, graft losses from HAT were similar between groups (low dose 2%, high dose 7% vs. low dose to high dose 0%, p = .56). CONCLUSION: The use of a standardized risk-adjusted anticoagulation protocol after pLT is associated with a low occurrence of thrombotic and hemorrhagic complications. High-dose anticoagulation leads to more bleeding, but those risks outweigh the risks of possible graft loss.

HEROES V-A: HEmoRrhagic cOmplications in veno-arterial Extracorporeal life Support: Development and internal validation of a multivariable prediction model in adult patients.

BACKGROUND: Risk factors for bleeding complications during extracorporeal life support (ECLS) indicated for cardiac support remain poorly investigated. The aim is to develop and internally validate a prediction model to calculate the risk for bleeding complications in adult patients receiving veno-arterial (V-A) ECLS. METHODS: Data of the Extracorporeal Life Support Organization registry of adult patients undergoing V-A ECLS between 2010 and 2020 were analyzed. The primary outcome was bleeding complications recorded during V-A ECLS. Multivariable logistic regression with backward stepwise elimination was used to develop the prediction model. Performance of the model was tested by discriminative ability and calibration with receiver operator characteristic, area under the curve, and visual inspection of the calibration plot. Internal validation was performed to detect overfitting of the model. RESULTS: In total 28 767 adult patients were included, of which 29.0% developed bleeding complications. Sex, body mass index, surgical cannulation, pre-ECLS respiratory and hemodynamic variables, pre-ECLS support and interventions, and different type of diagnosis were included in the prediction model. This prediction model showed a predictive capability with an AUC of 0.66. CONCLUSION: The model is based on the largest cohort of V-A ECLS patients and is the best available predictive model for bleeding events given the predictors that are available in V-A ECLS compared to current literature. The model can help in identifying patients at high risk for bleeding complications and will help in developing further research and decision-making in terms of anticoagulation management. External validation is warranted to extrapolate this model in the clinical setting.

Comparison of Hemorrhagic Complications with Double-ligated versus Auto-ligated Feline Ovarian Pedicles by Fourth-Year Veterinary Students.

The objective of this article is to compare the occurrence of hemorrhagic complications in student-performed feline ovarian pedicle ligations using the traditional suture pedicle double-ligation (PDL) to the suture-less auto-ligation (AL) techniques, and to describe the stepwise method of teaching the AL technique to students. A total of 287 cats underwent an ovariohysterectomy (OHE) performed by a fourth-year veterinary student trained by veterinary faculty to perform the AL technique beginning with a low-fidelity model and progressing to live patient surgeries. Students performed the AL and PDL techniques on 146 and 141 cats respectively. Hemorrhagic complications occurred in 4 of 146 cats (2.7%) in the AL group and 8 of 141 (5.7%) in the PDL group and were not found to be significantly different (p = 0.2496). This article demonstrates that novice surgeons can safely perform the AL technique on feline ovarian pedicles without significantly increasing complications compared to the traditionally taught method when a stepwise training program is implemented. Additionally, this technique has been shown to be safe, effective, and more efficient when performed by experienced veterinary surgeons.1 Veterinary institutions should consider including the AL technique in their core curricula as a standard method for feline ovarian pedicle ligation. Doing so will facilitate the development of more proficient entry-level practitioners who are better able to serve their patients, clients, employers, humane societies, and their communities by using a more efficient and safe feline ovariohysterectomy technique.

Device-related epistaxis risk: continuous-flow left ventricular assist device-supported patients.

BACKGROUND: The aim of this study was to analyze the effect of device-dependent factors on epistaxis episodes comparing patients supported with a continuous-flow left ventricular assist device (CF-LVAD) to patients under the same antithrombotic therapy. METHODS: Patients who underwent CF-LVAD between 2012 and 2018 were reviewed retrospectively from the institutionally adopted electronic database. Patients who underwent mitral valve replacement (MVR) surgery receiving the same anticoagulant and antiaggregant therapy were included as a control group. Demographics, epistaxis episodes, and nonepistaxis bleeding between the two groups were compared. RESULTS: A total of 179 patients met the inclusion criteria (61 patients CF-LVAD group, 118 patients MVR group). The median (range) follow-up periods for the study (CF-LVAD) and control (MVR) groups were 370 (2819) and 545.70 (2356) days, respectively. There was a significant difference for frequency of bleeding episodes per month between CF-LVAD and MVR groups (p = 0.003 < 0.05). The most common site of bleeding was the anterior septum in both groups (90.9% for the CF-MVR group and 100% for the MVR group). While 14 patients (23%) had nonepistaxis bleeding in the CF-LVAD group, only two patients (1.7%) had nonepistaxis bleeding in the MVR group. There were significant differences in nonepistaxis bleeding rates between the CF-LVAD and MVR groups (χ2=19.79, p < 0.001). CONCLUSION: Both epistaxis and nonepistaxis bleeding rates were higher in the CF-LVAD group than in the MVR group. This suggests that the use of CF-LVAD support could directly increase the risk of hemorrhagic complications. LEVEL OF EVIDENCE: 2A (Etiology/Harm).

[Resumption of anticoagulant therapy after major bleeding and recurrence of hemorrhagic complications in patients with atrial fibrillation with a high risk of stroke and thromboembolism (based on the results of 20 years of observation)].

AIM: To analyze the frequency of resumption of anticoagulant therapy (ACT) after major and clinically significant bleeding among AF patients who received oral anticoagulants and were observed in the Department of clinical problems of atherothrombosis from 1999 to 2019 within the retro-prospective register Regata-2, and to search for clinical factors associated with recurrence of hemorrhagic complications among patients who resumed anticoagulant therapy after a bleeding episode. MATERIALS AND METHODS: In cohort study of patients with high-risk AF with absolute indications for ACT we enrolled 290 AF patients (130 women and 160 men) aged 32 to 85 years (the average age was 65.188.89 years). During the follow-up period, 92 patients developed hemorrhagic complications, and 73 of them resumed ACT. 35 of the 73 patients who resumed ACT developed a relapse of major/clinically significant bleeding. RESULTS: The frequency of resuming ACT after the first hemorrhagic complication increased over time from 75% in the period from 19992003 to 90% in the period 20152019. We were not able to establish an exact relationship between the presence of concomitant pathology and the decision to resume the ACT after bleeding. The only reliable reason for refusing to resume the ACT was the patients categorical reluctance. Among patients who had recurrent hemorrhagic complications, the total score on the Charleson comorbidity scale was significantly higher (4.232.01vs3.521.43;p=0.0425). Patients with recurrent bleeding were significantly more likely to suffer from CKD with a decrease in GFR less than 60 ml/min/1.73 sq. m, and also had a history of erosive and ulcerative lesions of the gastrointestinal tract. There was also a significant Association of recurrent bleeding with the use of proton pump inhibitors. Subgroups of patients who switched from warfarin to taking direct oral anticoagulants after the first bleeding and subsequent recurrent bleeding did not differ in basic clinical characteristics from patients without bleeding after changing the anticoagulant. According to multiple regression analysis, NSAIDs showed a tendency to develop a relapse of B/C bleeding on the background of direct oral anticoagulants in patients who underwent GO on the background of warfarin therapy (b=0.4524,p=0.0530). CONCLUSION: During the 20-year follow-up, the frequency of all major and clinically significant bleeding was 2.6/100 patients-years, the frequency of first bleeding was 5.86/100 patients-years, while the frequency of repeated hemorrhagic complications was 7.06/100 patients-years. Patients with a high thromboembolic risk should receive anticoagulants, provided that the modifiable risk factors for bleeding are carefully corrected.

[Hemorrhagic complications risk forecast of operative treatment of urolithiasis].

INTRODUCTION: In the structure of hospital urological pathology, urolithiasis is about 40%, while 2/3 of patients are hospitalized for emergency reasons. Surgical treatment, even in a modern minimally invasive format, can cause postoperative complications in 10-30% of cases, of which up to 5% are hemorrhagic complications requiring blood transfusion in 0.7-1.4% of cases. MATERIALS AND METHODS: To determine the diagnostically significant risk factors for postoperative bleeding, the results of treatment of urolithiasis in 574 patients using remote lithotripsy were used. Based on the results of the statistical analysis, a computer program module "Method for predicting the development of hemorrhagic complications of the postoperative period in patients with urolithiasis" was developed. RESULTS: Of the 45 alleged risk factors for postoperative bleeding, 9 diagnostically significant ones were selected, including recurrent urolithiasis, a history of bleeding, hematuria, size and density of the calculus, and some indicators of the coagulogram. The threshold value of the amount of bleeding risk assessment in points is set to 8, that is, a result of more than 8 points corresponds to a high risk of bleeding. It was established that the risk of hemorrhagic complications in the postoperative period in urolitiasis increases with large stones (size from 5 mm) with high density (from 400 HU), with a decrease in the number of platelets (from 1701012/l) and lengthening of AChTV (from 40 c), PV (from 15 s) and TV (from 16 s), as well as in the presence of a history of recurrent urolithiasis, bleeding and preoperative microhematuria. CONCLUSION: The developed computer program module allows you to quickly and objectively assess the risk of hemorrhagic complications at the stage of choosing the method of surgery, conduct preoperative prophylaxis and increase the effectiveness of surgical treatment of urolithiasis.

[Blood-saving technologies in extensive liver resections]. / Taktika krovosberezheniya pri obshirnykh rezektsiyakh pecheni.

The researches devoted to blood-saving technologies in extensive liver resections are analyzed in the manuscript. Resection of three and more liver segments is effective method of surgical treatment of various focal liver lesions. Surgical (anatomical resection with hilar glissonean access, Pringle maneuver, modern technical equipment, etc.), anesthesiological (reduction of central venous pressure, hemostatic agents) and transfusion (autologous blood donation, transfusion, cell saver, etc.) methods contribute to prevention and reduction of blood loss. Intraoperative measures for blood loss prevention should include adequate surgical incision and liver mobilization, precise techniques of parenchymal dissection (for example, cavitation surgical aspirator-destructor), use of clip applicators and local or systemic hemostatic agents.

Effect of preoperative antiplatelet or anticoagulation therapy on hemorrhagic complications in patients with traumatic brain injury undergoing craniotomy or craniectomy.

OBJECTIVE: Traumatic brain injury (TBI) is common among the elderly, often treated with antiplatelet (AP) or anticoagulation (AC) therapy, creating new challenges in neurosurgery. In contrast to elective craniotomy, in which AP/AC therapy is mostly discontinued, in TBI usually no delay in treatment can be afforded. The aim of this study was to analyze the effect of AP/AC therapy on postoperative bleeding after craniotomy/craniectomy in TBI. METHODS: Postoperative bleeding rates in patients treated with AP/AC therapy (blood thinner group) and in those without AP/AC therapy (control group) were retrospectively compared. Furthermore, univariate and multivariate analyses were conducted to identify risk factors for postoperative bleeding. Lastly, a proportional Cox regression analysis comparing postoperative bleeding events within 14 days in both groups was performed. RESULTS: Of 143 consecutive patients undergoing craniotomy/craniectomy for TBI between 2012 and 2017, 47 (32.9%) were under AP/AC treatment. No significant difference for bleeding events was observed in univariate (40.4% blood thinner group vs 36.5% control group; p = 0.71) or Cox proportional regression analysis (log rank χ2 = 0.29, p = 0.59). Patients with postoperative bleeding showed a significantly higher mortality rate (p = 0.035). In the univariate analysis, hemispheric lesion, acute subdural hematoma, hematological disease, greater extent of midline shift, and pupillary difference were significantly associated with a higher risk of postoperative bleeding. However, in the multivariate regression analysis none of these factors showed a significant association with postoperative bleeding. CONCLUSIONS: Patients treated with AP/AC therapy undergoing craniotomy/craniectomy due to TBI do not appear to have increased rates of postoperative bleeding. Once postoperative bleeding occurs, mortality rates rise significantly.

Risk Factors for Hemorrhagic and Cardioembolic Complications of Intracerebral Hemorrhage Associated with Anticoagulants.

BACKGROUND: Patients with intracerebral hemorrhage taking anticoagulants are increasingly common in Japan due to the aging population. The clinical benefit of restarting anticoagulants is established, but the optimal timing of resumption is controversial. Risk factors for hemorrhagic and cardioembolic events in the acute phase are also unknown. This study investigated hemorrhagic and cardioembolic events and risk factors in intracerebral hemorrhage patients taking anticoagulants. METHODS: The clinical data of 65 consecutive intracerebral hemorrhage patients taking anticoagulants were retrospectively reviewed. Hemorrhagic and cardioembolic complications and risk factors were analyzed. RESULTS: Lobar hemorrhage was the most frequent (21 of 65 cases, 32.3%). At discharge, 31 patients (47.7%) showed severe disability or had died. Eight (18.6%) of 43 patients who restarted anticoagulants after initial treatment developed hemorrhagic events, including recurrent intracerebral hemorrhage in 3. HAS-BLED score was 2-3 in these 3 patients. Six (15.8%) of 38 patients who took anticoagulants for cardiogenic factors suffered cardioembolism. Systemic inflammatory response syndrome was significantly more common in the cardioembolic group (66.7%) compared with the noncardioembolic group (21.9%, P < .05). CHA2DS2-VASc score was paradoxically high in the noncardioembolic group (3 versus 5, P < .05). CONCLUSION: HAS-BLED score and CHA2DS2-VASc score were not useful for risk assessment for hemorrhagic events, recurrent intracerebral hemorrhage, and cardioembolism in the acute phase. Inflammatory response might be important in the occurrence of cardioembolic events.

[Method of preventing late hemorrhagic complications after surgical treatment of secondary neovascular glaucoma]. / Metod profilaktiki pozdnikh gemorragicheskikh oslozhnenii posle khirurgicheskogo lecheniia vtorichnoi neovaskuliarnoi glaukomy.

The existing methods of surgical treatment of secondary neovascular glaucoma (NVG) in 50-55% of cases are accompanied by hemorrhagic complications, which lead to persistent increase of intraocular pressure (IOP), complete loss of vision and even eye death. Decreasing the risks of hemorrhagic complications after surgical treatment of secondary NVG is one of topical problems of ophthalmology. PURPOSE: To study the effectiveness of a new method of preventing late hemorrhagic complications of surgical treatment of secondary NVG after central retinal vein occlusion (CRVO). MATERIAL AND METHODS: The study included 148 patients (150 eyes) with secondary NVG after CRVO. The patients were divided into two groups: 98 patients (100 eyes) of the 1st group underwent sinustrabeculectomy with cyclovitrectomy and traditional surgery preparation and post-op treatment; the second group consisted of 50 patients (50 eyes) who received surgical treatment in combination with interferon therapy. All patients were observed for 1.5 years with necessary ophthalmic examination methods. RESULTS: At the end of the follow-up, the second group showed statistically significant (p<0.01) reduction in the rates of hemorrhagic complications by 80%, progression of neovascularization of the iris and structures of the angle of anterior chamber of the eye by 50%, progression of neovascularization of the retina accompanied by the development of fibrosis of posterior hyaloid membrane by 37%. Reduction of the rate of complications positively affected the functional and tonometric results leading to improved visual acuity and preservation or even widening of the field of vision by 118%, as well as 60% improvement of tonometric results. CONCLUSION: The newly developed method of preventing post-surgical complications allowed significant reduction of the risks of hemorrhagic complications and improvement of functional and tonometric results of surgical treatment of patients with secondary NVG after CRVO.

Impact of HAS-BLED score to predict trans femoral transcatheter aortic valve replacement outcomes.

BACKGROUND: Predictors of bleeding and mortality after trans femoral transcatheter aortic valve replacement (TF-TAVR) has not been thoroughly investigated. OBJECTIVE: The aim of this study was to assess whether Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly, Drugs/alcohol concomitantly (HAS-BLED) score has predictive value for bleeding and mortality in patients after TAVR. METHODS: Between October 2013 and April 2016, 969 patients underwent TF-TAVI were prospectively included in the OCEAN-TAVI registry from Japan. The primary outcomes were severe bleeding (including life-threatening and major bleeding defined in The Valve Academic Research Consortium-2 criteria) and mortality within 1 year after TAVR. RESULTS: Elderly (84 ± 5 years) and high surgical risk patients (The Society of Thoracic Surgery Risk Score 6.7 [4.6-9.3]) were enrolled. Severe bleeding and mortality had occurred in 177 patients (18.2%) and 66 patients (6.8%), respectively. On multivariate analysis, HAS-BLED score was associated with severe bleeding (hazard ratio [HR], 1.82; 95% confidence interval [CI], 1.41-2.00; p < 0.001) and mortality (HR, 2.04, 95% CI, 1.56-2.69, P < 0.001). A HAS-BLED score threshold of 4 points (area under the curve 0.71 for severe bleeding, 0.72 for mortality) predicted a higher rate of severe bleeding (25.3% vs. 14.4%, P < 0.001) and mortality (16.2% vs. 4.0%, P < 0.001). CONCLUSIONS: HAS-BLED score could predict the risk of severe bleeding and mortality in patients who underwent TF-TAVR independent of the presence of atrial fibrillation.

[Anticoagulant therapy in atrial fibrillation with acute coronary syndrome in real clinical practice according to the total register of acute coronary syndrome in the Krasnodar Territory].

OBJECTIVE: to analyze patients with first-time developing atrial fibrillation (AF), against acute coronary syndrome (ACS), risk factors for arrhythmia, assessment of patients' adherence to oral anticoagulant therapy 6-24 months after the ACS episode, according to the total ACS registry for the Krasnodar Territory. MATERIALS AND METHODS: A retrospective analysis of the case histories of 13,244 patients admited to the infarction departments of all setlements of the Krasnodar Territory without exception and included in the ACS registry for the Krasnodar Territory from November 20, 2015 to January 20, 2018. RESULTS: The study group of ACS with AF included 201 patients, among them 144 men (71.642%), women 57 (28.358%). The average age was 68,084 ± 9,606 years, a maximum of 85 years, a minimum of 25 years. The frequency of the following outcomes was assessed: hospital mortality, frequency of hemorrhagic, thromboembolic complications. The effectiveness of prognostic scales of development of hemorrhage CRUSADE and HAS BLED was evaluated and the expediency of prescribing extended OAT to patients with the first developed AF atack against the background of ACS after discharge from the hospital. CONCLUSIONS: Based on the obtained results, based on the data of the total ACS register for the Krasnodar Territory, we can conclude: 1. Patients with a newly developed episode of AF on the background of ACS have demographic, anamnestic data comparable with other types of AF; 2. Patients with a newly developed AF episode on the background of ACS have a more severe course of the disease, which does not affect hospital mortality, hospital complications and lethality after 6-24 months after discharge from the hospital for ACS; 3. Patients with a newly developed episode of AF on the background of ACS after discharge from the hospital do not have arrhythmia recurrences, they do not have thromboembolic complications. The decision on the duration of oral anticoagulant therapy should be carried out afer carrying out a multi-day monitoring of the ECG.

[Inhibitory and mild forms of hemophilia: diagnostic difficulties, surgical complications]. / Trudnosti diagnostiki i khirurgicheskie oslozhneniia pri razlichnykh formakh gemofilii.

AIM: To identify patients with hemophilia who have a high risk of postoperative hemorrhagic complications. MATERIAL AND METHODS: Prospective trial included 69 patients aged 18-71 years (median 29) with congenital hemophilia A and B. They underwent elective and emergency treatment for abdominal and thoracic pathology at the National Medical Research Center for Hematology in 2011-2016. Patients with mild and inhibitory forms of hemophilia were compared with those with severe and moderate forms of hemophilia. There were 50 (73%) patients with severe and moderate forms of hemophilia, 8 (11%) with inhibitory and 11 (16%) patients with mild form. Emergency operations were performed in 18 cases, elective - in 51. RESULTS: Inhibitory form of hemophilia is associated with 1.5 times higher (95% CI, 1.1-3.0) risk of hemorrhagic postoperative complications and death and 3,5 times higher (95% CI 1.7-5.9) risk of redo surgery compared with severe and moderate forms (p<0.05). Risk of hemorrhagic postoperative complications is also higher in patients with mild form of hemophilia compared with severe and moderate forms (1/6 vs. 1/50; p=0.05). CONCLUSION: The risk of postoperative hemorrhagic complications is significantly higher in inhibitory and mild hemophilia compared with severe and moderate forms and associated with hemostatic therapy defects and inadequate assessment of hemostatic disorders. Long-standing haemorrhagic syndrome should be followed by blood clotting system analysis including evaluation of procoagulant activity, presence of inhibitor, and thromboelastography. Decreased levels of albumin (by 2.9-8.6% in our trial) and cholesterol (by 6.5-54.8%) reflects impaired liver function and is sign of unfavorable prognosis. This finding should be considered for surgery and therapy of hemorrhagic manifestations.

Optimal pediatric dosing of anti-platelet agents for pipeline stent embolization -a case report and review of the literature.

BACKGROUND: Various strategies are emerging for dosing antiplatelet therapies in preparation for pipeline stent embolization in adults. Hyper-response is associated with hemorrhagic complications. Hypo-response is associated with thromboembolic events. Dosing of antiplatelet agents is highly variable, with little consensus among experts for adults-and even more so for children. To date, pipeline stents have been deployed in 11 pediatric patients, ages 4-15. A variety of clopidogrel and aspirin dosing regimens have been used, with response tested in only three patients, who were all therapeutic. Thrombotic events occurred in two patients, neither of whom were tested. CASE: We describe here the first case of a hemorrhagic complication in a hyper-responsive pediatric patient undergoing placement of a pipeline stent. DISCUSSION: As the use of endovascular therapies requiring dual anti-platelet agents becomes more established, there is an increasing need to develop titration protocols that minimizes the risk of thrombotic and hemorrhagic events.

[Anticoagulant therapy in patients with atrial fibrillation and reduced kidney function of diabetic and non-diabetic etiologies]. / Antikoaguliantnaia terapiia u patsientov s fibrilliatsiei predserdii i snizhennoi funktsiei pochek diabeticheskoi i nediabeticheskoi étiologii.

AIM: To evaluate the efficacy and safety of direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) and stages I-III chronic kidney disease (CKD). SUBJECTS AND METHODS: The cohort parallel-group study included 92 patients with AF and stages I-III diabetic and non-diabetic CKD, who were treated with DOACs (dabigatran, rivaroxaban, or apixaban) and vitamin K antagonists (warfarin). The follow-up duration was 12 months. RESULTS: Thromboembolic events and bleeding, which required patient hospitalization or blood transfusions, were not recorded during 1-year follow-up. There was no clinically significant progression of CKD in the groups of therapy with vitamin K antagonists or DOACs. Just the same, a more intense decrease in glomerular filtration rate and a high rate of hemorrhagic complications were revealed in the subgroup of patients with diabetes mellitus (DM) versus those with non-diabetic CKD. CONCLUSION: In patients with non-valvular AF and diabetic and non-diabetic CKD, the use of DOACs effectively and safely prevents thromboembolic events, irrespective of the stage of CKD. At the same time, in patients taking anticoagulants, CKD progresses more rapidly in the presence of DM than in its absence, regardless of a specific anticoagulant. Hemorrhagic complications are more common in patients with AF, DM, and CKD, which requires more frequent monitoring of their kidney function.

[In-hospital Outcomes and Complications of Percutaneous Coronary Interventions in Acute ST-Elevation Myocardial Infarction in Different Age Groups].

AIM: to assess early (in-hospital) results of percutaneous coronary intervention (PCI) for ST-elevation (STE) myocardial infarction (MI) in different age groups. MATERIALS AND METHODS: We enrolled in this study 356 patients with STEMI who underwent PCI within 24 hours of the disease during 1 year (2012). According to age all patients were divided into 2 groups: "young" ( less or equal 70 years) and "older" (>70 years). RESULTS: Compared with young in older group there were more patients with renal (53.84 vs. 19.78%) and myocardial (23.07 vs. 6.83%, =0.0000) dysfunction, hypertension (97.43 vs. 83.81% =0.0018), history of MI (19.23 vs. 10.43%, =0,3736), and acute heart failure at admission (32.04 vs. 13.95%, =0.0003), and less smokers (10.25 vs. 34.53%). Hospital mortality in older group was higher (8.97 vs. 1.43%, =0.0007) despite effective PCI. Rate of hemorrhagic complications (major bleedings+hemotransfusions) was also higher in older group (5.12 vs. 0.71%, =0.0077). CONCLUSION: Compared with younger older STEMI patients were characterized by more severe initial clinical condition and worse early results of primary PCI with higher mortality and rate of hemorrhagic complications. Thus the problem of improvement of management of this group of patients during hospitalization remains to be actual.

A Study on the Efficacy and Safety of Pipeline Shield Stents and Nonmodified Surface Flow-Diverting Stents in Patients with Intracranial Aneurysms.

BACKGROUND: Few studies have compared the Pipeline Shield stents with previous generations of flow-diverting stents (FDSs) for the treatment of unruptured intracranial aneurysms. This study aimed to evaluate the efficacy and safety of Pipeline Shield stents and FDSs without modified surfaces. METHODS: The present evaluation is a retrospective cohort study of patients endovascularly treated with Pipeline Shield stents or FDSs without modified surfaces for unruptured intracranial aneurysms between January 2014 and June 2022. The data analyzed were obtained from the anonymized database of our institution's interventional radiology service. RESULTS: A total of 147 patients with 155 unruptured intracranial aneurysms were included. Of the 155 aneurysms, 96 were treated with Pipeline Shield stents and 59 with FDSs without modified surfaces. The aneurysms treated with Pipeline Shield stents had higher 6-month (O'Kelly-Marotta [OKM] D; 87.5% vs. 71.4%; P = 0.025) and 1-year (OKM D; 82.5% vs. 63.0%; P = 0.047) occlusion rates than the aneurysms treated using FDSs without modified surfaces. No differences between the devices were found at the 1-year follow-up in the incidence of ischemic stroke (P = 0.939) or hemorrhagic complications (P = 0.559). CONCLUSIONS: Pipeline Shield stents demonstrated superior complete occlusion rates (OKM D) at both the 6-month and the 1-year follow-up assessments compared with nonmodified surface FDSs. No significant differences were found in the safety profiles between the 2 types of stents with regard to thromboembolic complications and ischemic events. Further research with larger study populations is necessary to validate these findings.