Efficacy and safety of peri-procedural bridging therapy with low molecular weight heparin in atrial fibrillation patients under vitamin K antagonists.

BACKGROUND: The clinical effect of peri-operative bridging therapy in atrial fibrillation (AF) patients remains unclear given that it may increase bleeding risk without providing significant benefits. We aimed to investigate peri-procedural events in relation to peri-operative use of bridging therapy in AF patients under Vitamin K Antagonists (VKAs). METHODS: We included AF patients stable the previous 6 months on VKAs. During a median follow-up of 6.5 years (IQR 4.3-7.9), we recorded all invasive procedures and the peri-operative clinical management. All peri-procedural events (ischaemic stroke/transient ischaemic attack/systemic embolism, clinically relevant non-major bleeding and major bleeding) and severe peri-procedural events (ischaemic stroke/transient ischaemic attack/systemic embolism and major bleeding) suffered until the 30-days post-intervention period were recorded. RESULTS: We included 1361 patients (48.7% male, median age 76 [IQR 71-81] years). There were 1100 (70.9%) procedures performed using bridging therapy. The rate of any (4.5% vs. 0.7%, P < 0.001) and severe (2.3% vs. 0.0%, P = 0.002) peri-procedural events were higher in patients receiving bridging therapy. Adjusted logistic regressions demonstrated that the bleeding risk of the procedure was related with higher risk of severe peri-procedural events (OR 3.51, 95% CI 1.54-8.01) and peri-procedural events (OR 2.77, 95% CI 1.56-4.91). Importantly, the use of bridging therapy was also independently associated with higher risk of any peri-procedural events (OR 4.32, 95% CI 1.28-14.51). CONCLUSIONS: In this study including AF patients under VKA therapy, the use of bridging therapy as part of the clinical management during an invasive procedure was independently associated with higher risk of any peri-procedural event.

[Percutaneous nephropexy in the treatment of renal ptosis]. / Nefropexia percutánea para el tratamiento de la ptosis renal.

OBJECTIVE: Surgical fixation of ptotic kidneys has been utilized since the late nineties of the last century and more than 170 techniques have been described in the literature, all of which are by open surgery. The efficacy of a new percutaneous nephropexy procedure is described herein. METHODS: The technique basically consists in the fixation of the organ in its normal position by fibrous ligation created by a nephrostomy (preferably loop nephrostomy) and a nephropyeloureteral catheter inserted percutaneously. Our technique of percutaneous nephropexy was performed in 15 female patients with marked right renal ptosis, a long history of pain, which was complicated by lithiasis in the same kidney in 5 cases, and in whom medical treatment had repeatedly failed. RESULTS: At 6-14 months' follow-up, all of the patients are asymptomatic with negative urological cultures, no calculi, kidney in normal position and ureter corrected. CONCLUSIONS: The results demonstrate that our percutaneous nephropexy technique is an effective alternative treatment for the old and unresolved problem of renal ptosis.

[Staghorn calculi. Combined treatment with percutaneous nephrolithotripsy and extracorporeal lithotripsy]. / Litiasis coraliforme. Tratamiento combinado con nefrolitotricia percutánea y litotricia extracorpórea.

We present our experience in 61 patients with partial or complete staghorn stone who underwent combined treatment with PCN and ESWL. We excluded the cases with an additional factor complicating staghorn stone, such as horseshoe kidney, severe ectopic, mal-rotated or high, with pyeloureteral junction stricture, etc. The patients were submitted to 72 PCN and 113 ESWL sessions, 5 percutaneous nephrostomies prior to PCN and 5 ureteroscopy procedures to remove post-ESWL obstruction. Complications were observed in 24.5%; acute urinary infection post-PCN (13 patients, 21.3%), massive absorption of liquid (1 case) and arteriovenous fistula (1 case). One year following treatment 83.6% of the patients are stone free and 14.9% have residual stone fragments. No patients developed arterial hypertension and one patient was submitted to nephrectomy due to pyelonephritic atrophy. Our criteria concerning the indications for the different therapeutic methods are discussed. In our view, the role of each method must be reviewed in the light of current clinical experience and investigative data.

[Percutaneous nephrostomy associated with extracorporeal shockwave lithotripsy in the treatment of renoureteral lithiasis]. / Nefrostomía percutánea asociada a litotricia extracorpórea por ondas de choque en el tratamiento de la litiasis renoureteral.

From a series of 5000 cases that had undergone extracorporeal shock wave lithotripsy at the Hospital Clinico Quirúrgico "Hermanos Ameijeiras" from March, 1986 to April, 1988, 220 cases that required percutaneous nephrostomy due to obstructive hydronephrosis from stone fragments were studied. We analyzed the clinical, radiological and ultrasound features of these cases, as well as the criteria for performing percutaneous nephrostomy. We identified the risk factors that made the procedure necessary, particularly urinary tract infection. No important complications ascribable to the foregoing procedure were observed. Performing the procedure early improved patient clinical course and reduced cost of treatment. To eliminate stone fragments completely, percutaneous nephrostomy was combined with other procedures in 198 cases (90%). The stone fragments were passed spontaneously in 10 cases (4.5%) following diversion. At 2 months 190 cases (86%) were completely stone free, 18 (8%) had residual stones and 12 (6%) required open surgery. The foregoing results show that percutaneous nephrostomy is a very useful procedure in septic-obstructive complications following extracorporeal shock wave lithotripsy and acquiring the skill to perform it is essential.

[Percutaneous nephrolitholapaxy combined with extracorporeal shockwave lithotripsy in the treatment of staghorn lithiasis]. / Nefrolitotricia percutánea asociada a litotricia extracorpórea por ondas de choque en el tratamiento de la litiasis coraliforme.

From December, 1988 to July, 1989, 41 patients with renal or juxtapyelic ureteral calculi were submitted to percutaneous litholapaxy (PCN) at the Stone Center of the Hermanos Amerijeiras Hospital in Havana. This series comprise our early experience utilizing this procedure. PCN was initially limited to pelvic and juxtapyelic ureteric calculi with dilated renal cavities. It was subsequently used in combination with extracorporeal lithotripsy (ESWL) in the treatment of staghorn stones. The present study analyzed the results achieved with PCN in 30 patients with staghorn calculi; 21 (70%) incomplete staghorns and 9 (30%) complete staghorns. Posteriorly, 6 additional borderline staghorns were completely removed by PCN and are not included in the present study. PCN was performed to reduce stone mass and for placement of a large renal drain to permit subsequent ESWL. At two months following treatment, 86.6% of the patients were completely stone-free. The remaining 13.4% with stone remnants presented anatomic and functional renal conditions that allow us to predict complete elimination within a short period of time. Since 6 months had not elapsed in these cases, these were not considered as residual fragments. One patient presented massive absorption of fluids. This was the only observed major and non-lethal complication. Episodes of fever were observed in 23% post-PCN. No patient presented severe sepsis. In our view, PCN combined with ESWL is one of the currently available therapeutic options in the treatment of staghorn calculi. This approach permits adequate resolution of cases that would have otherwise required surgery.

[Treatment of renoureteral lithiasis using extracorporeal shockwave lithotripsy. Experience in Cuba]. / Tratamiento de la litiasis renoureteral mediante litotricia extracorpórea por ondas de choque. Experiencia en Cuba.

Herein we present our experience in 5,000 cases of reno-ureteral lithiasis submitted to treatment at the Extracorporeal Lithotripsy Unit of Hermanos Ameijeiras Hospital in Havana, Cuba, from April 1986 and during a period spanning 30 months. Treatment was exclusively by extracorporeal shock wave lithotripsy (ESWL) in 85.5% of the patients and in combination with other procedures in 14.5% (endoscopic maneuvers in 5.9%, percutaneous nephrostomy 4.4%, open surgery 3.6%, and percutaneous nephrolithotripsy 0.6%). Complications were observed in 7% of the cases: ureteric obstruction (6.4%) with or without infection, perirenal hematoma (0.4%), and obstructive anuria (0.2%); acute urinary infection of different clinical types, some of which were very severe, were observed concomitantly in 2.6% of these patients. Two months following treatment, 86% of the cases were completely stone-free. At 6 months 96.2% were completely stone-free; the remaining 3.8% were classed as residual lithiasis. The pathologic conditions that put patients at high therapeutic risk and the possible complications that could arise were identified. The efficacy of the Dornier HM-3 lithotripter and the health care system that permits its extensive use are highlighted.