Young-onset stroke complicating ulcerative colitis

A 16-year-old girl developed a proximal occlusion of the right middle cerebral artery during a flare-up of acute ulcerative colitis. Although mechanical thrombectomy led to successful middle cerebral artery recanalisation, she required an immediate second thrombectomy due to reocclusion of the same arterial segment. She developed a second ischaemic event 7 days later despite intravenous heparin infusion, later switched to low-molecular-weight heparin, and a third event after 3 days despite the addition of aspirin. We discuss stroke risks in people with inflammatory bowel disease and the uncertainties around anticoagulation and antiplatelet regimens in such cases.

Hybrid revascularization of the heart and brain: which carotid endarterectomy is preferable?

The aim of this study was to analyse the inpatient and long-term results of hybrid surgery, incorporating percutaneous coronary intervention (PCI) and different types of carotid endarterectomy (CEA). Materials and methods. A prospective, open-label cohort comparison study was conducted in 20182020 and included 363 patients with atherosclerosis of both the internal carotid artery (ICA) and coronary artery, who underwent hybrid revascularization of the brain and myocardium. All patients were divided into four groups based on the revascularization strategy: group 1 (n = 107; 29.5%) PCI + eversion CEA; group 2 (n = 98; 27%) PCI + classic CEA with patch angioplasty; group 3 (n = 72; 19.8%) PCI + glomus-sparing CEA according to R.A. Vinogradov; and group 4 (n = 86; 23.7%) PCI + glomus-sparing CEA according to A.N. Kazantsev. The follow-up period was 20.8 8.0 months. The patient received a loading dose of clopidogrel (300 mg) before the PCI, and the procedure was then performed in an endovascular operating room. A radial artery catheter was inserted, and the patient received 10,000 IU of intravenous heparin before the procedure. After the PCI, the patient was taken to the vascular operating room, where they underwent the CEA. The patient received 5,000 IU of intravenous heparin before artery clamping. Glomus-sparing CEA according to A.N. Kazantsev was performed as follows: an arteriotomy was conducted along the internal edge of the external carotid artery (ECA), adjacent to the carotid sinus and 23 cm above the ostium, and extending to the common carotid artery (CCA) (also 23 cm below the ECA ostium), depending on the size of the atherosclerotic plaque. The ICA was transected in the area bound by the ECA and CCA walls. Eversion CEA of the ICA was performed, followed by open CEA of the ECA and CCA. The ICA was implanted in its previous position in the preserved area. Results. No mortality was recorded during the inpatient follow-up period. All cases of myocardial infarction occurred after eversion and classic CEA: 3 in group 1 (2.8%) and 1 in group 2 (1.02%); р = 0.2. No ischaemic stroke was recorded only in patients who underwent CAE according to A.N. Kazantsev (р = 0.66); however, ischaemic stroke occurred in two patients in group 1 (1.8%), in two patients in group 2 (2.04%) and in one patient in group 3 (1.38%). The highest number of cardiovascular events occurred in group 1, due to carotid glomus injury, which led to poorly controlled hypertension during the inpatient stay. This tendency influenced the composite endpoints (death + myocardial infarction + ischaemic stroke), which were highest in group 1 (5 or 4.6%) compared to 3 (3.06%), 1 (1.38%) and 0 in groups 24, respectively (р = 0.18). The groups were comparable in the frequency of long-term complications. However, the incidence of ICA restenosis was lowest and no ECA thrombosis/occlusion was observed after glomus-sparing CEA according to R.A. Vinogradov and A.N. Kazantsev. Conclusion. A hybrid PCI + CEA for brain revascularization should be glomus-sparing. CEA according to A.N. Kazantsev was characterized by lack of procedural arteriotomy complications. This procedure enables blood pressure monitoring in the postoperative period, thus minimizing the risk of cardiovascular complications.

Role of acquired von Willebrand syndrome in the development of bleeding complications in patients treated with Impella RP devices

Axial flow pumps are standard treatment in cases of cardiogenic shock and high-risk interventions in cardiology and cardiac surgery, although the optimal anticoagulation strategy remains unclear. We evaluated whether laboratory findings could predict bleeding complications and acquired von Willebrand syndrome (avWS) among patients who were treated using axial flow pumps. We retrospectively evaluated 60 consecutive patients who received Impella devices (Impella RP: n = 20, Impella CP/5.0: n = 40; Abiomed Inc., Danvers, USA) between January 2019 and December 2020. Thirty-two patients (53.3%) experienced major or fatal bleeding complications (Bleeding Academic Research Consortium score of > 3) despite intravenous heparin being used to maintain normal activated partial thromboplastin times (40–50 s). Extensive testing was performed for 28 patients with bleeding complications (87.5%). Relative to patients with left ventricular support, patients with right ventricular support were less likely to develop avWS (87.5% vs. 58.8%, p = 0.035). Bleeding was significantly associated with avWS (odds ratio [OR]: 20.8, 95% confidence interval [CI]: 3.3–128.5; p = 0.001) and treatment duration (OR: 1.3, 95% CI 1.09–1.55; p = 0.003). Patients with avWS had longer Impella treatment than patients without avWS (2 days [1–4.7 days] vs. 7.3 days [3.2–13.0 days]). Bleeding complications during Impella support were associated with avWS in our cohort, while aPTT monitoring was not sufficient to prevent bleeding complications. A more targeted anticoagulation monitoring might be needed for patients who receive Impella devices.

Seraph-100 Hemoperfusion in SARS-CoV-2-Infected Patients Early in Critical Illness: A Case Series

There is an urgent need for therapeutic interventions to alter the course of critically ill coronavirus disease 2019 (CO­VID-19) patients. We report our experience with the Seraph-100 Microbind Affinity Blood Filter (Seraph-100) in 4 patients with COVID-19 early in the course of their critical respiratory illnesses. Patients were diagnosed with COVID-19 and were admitted to intensive care with worsening respiratory failure but did not require dialysis or vasopressors. Patients had to have a PaO₂ to FiO₂ (P/F ratio) <150 to qualify for hemoperfusion therapy. All patients received standard medical therapy including oral vitamins C and D and zinc in addition to intravenous dexamethasone and remdesivir. Patients received a single 5- to 7-h session with Seraph-100 on a conventional dialysis machine (Fresenius 2008T) via a nontunneled central venous dialysis catheter with a goal of processing at least 100 L of blood. Patients received weight-based subcutaneous enoxaparin anticoagulation, as well as systemic intravenous heparin (70 units/kg), just prior to hemofiltration. Treatment with Seraph-100 hemoperfusion was well tolerated, and all patients were able to finish their prescribed therapy. All patients treated with Seraph-100 survived to be discharged from the hospital. Well-designed clinical trials are needed to determine the overall safety and efficacy of the Seraph-100 Microbind Affinity Blood Filter in COVID-19 patients.

Successful Use of Apixaban for Paget-Schroetter Syndrome in a Pediatric Patient

Paget-Schroetter syndrome (PSS) is a rare syndrome that typically develops in young, healthy males subjected to repetitive overhead motions resulting in compression and thrombosis of the subclavian vein. This “effort thrombosis” typically occurs acutely in patients with specific anatomic variations within the thoracic outlet and is treated by a combination of surgical and pharmacologic interventions. There is a paucity of literature regarding this syndrome, particularly surrounding pharmacotherapy, and in the treatment of pediatric patients. This case report documents the pharmacologic treatment of a 17-year-old, male, baseball player with confirmed PSS. Apixaban was selected as the anticoagulant therapy of choice following the determination of its safety and anticipated efficacy for this pediatric patient. Upon admission, anticoagulation was initiated with intravenous heparin and transitioned to warfarin for 1 dose. On day 2, the patient was discharged with apixaban 10 mg twice daily for 7 days, followed by 5 mg twice daily. One week later, he underwent catheter-directed thrombectomy, followed by thoracic outlet decompression with resection of the first rib. Apixaban therapy was continued for 10 weeks after the procedure to diminish the risk of any further thrombotic events. This pediatric patient with PSS was successfully treated with apixaban in conjunction with surgical management. Treatment with apixaban resulted in continued resolution of thrombus after follow-up, with no complications reported thereafter. Further research is needed to definitively determine the safety and efficacy of apixaban for the use of pediatric anticoagulation, particularly in upper extremity deep vein thrombosis.

Pheochromocytoma Rupture Associated With Systemic Anticoagulation: A Case Report

Background: Pheochromocytoma rupture is a rare endocrine emergency. There have been approximately 85 documented cases, and the mortality rate for patients who require emergent surgery is as high as 34% (1). Clinical Case: A 30-year-old man with no past medical history presented to the Emergency Department with abdominal pain and vomiting. He was hypertensive, tachycardic, and hypoxic. CT Chest Angiogram revealed bilateral pulmonary emboli and a 6.5 x 5.5 x 6.4 cm left heterogenous adrenal mass. His plasma free metanephrines were elevated to 31,173 pg/mL (n<62 pg/mL) with normetanephrines >50,000 pg/mL (n<145 pg/mL). His pulmonary emboli was treated with continuous intravenous heparin, and he was also treated with intravenous fluids and phentolamine due to concern for pheochromocytoma. Within hours, he became hypotensive, and his hemoglobin downtrended from 16.4 g/L to 7.3 g/L (n 14–18 g/L). Repeat CT showed that the adrenal mass had ruptured, enlarging to 15.4 x 9.7 x 10.0 cm. He was taken for an emergent laparotomy with piecemeal resection of the mass; surgical pathology confirmed a pheochromocytoma. Fortunately, the patient recovered well after surgery. After 6 months, his plasma free metanephrines normalized to 15 pg/mL with normetanephrines of 80 pg/mL. His DOTATATE scan was negative for malignancy and his genetic testing was negative. Conclusion: The patient’s systemic anticoagulation and critical illness likely increased his risk for pheochromocytoma rupture. Standard preoperative pheochromocytoma management, to include aggressive fluid resuscitation and alpha blockade, is important in reducing risk of morbidity and mortality. Biochemical follow up is required, as there is a 16% risk of recurrence. Reference: (1) Kobayashi T, Iwai A, Takahashi R, Ide Y, Nishizawa K, Mitsumori K. Spontaneous rupture of adrenal pheochromocytoma: Review and analysis of prognostic factors. Journal of Surgical Oncology. 2005;90(1).

Recurrent thrombosis of an arteriovenous fistula as a complication of COVID-19 in a chronic hemodialysis patient: A case report

Patients with end-stage kidney disease are at increased risk of death from coronavirus disease 2019 (COVID-19). In addition, severe COVID-19 has been associated with an increased risk of arterial and venous thromboses. In this report, we describe the case of a hemodialysis patient who developed an otherwise-unexplained thrombosis of an arteriovenous fistula during a symptomatic COVID-19 infection. Despite prompt treatment with three technically successful thrombectomies along with systemic intravenous heparin and two rounds of catheter-directed thrombolysis with tissue plasminogen activator, the fistula rapidly re-thrombosed each time and he required tunneled dialysis catheter placement. He subsequently required admission for hypoxemia from COVID-19 pneumonia and ultimately developed a catheter-related blood stream infection that likely contributed to his death. As the fistula had been previously well functioning and no angiographic explanation for the thrombosis was found, we speculate in this case the recurrent thromboses were related to the hypercoagulable state characteristic of severe COVID-19. Interventionalists performing hemodialysis access procedures should be aware of the prothrombotic state associated with COVID-19 and should consider it when deliberating how to best plan and approach access interventions in patients with symptomatic COVID-19.

High-dose steroid and heparin: a novel therapy for cerebral vasculitis associated with presumed group A Streptococcus meningitis

Cerebral vasculitis is a serious complication of bacterial meningitis that can cause significant morbidity and mortality due to stroke. Currently, there are no treatment guidelines or safety and efficacy studies on the management of cerebral vasculitis in this context. Herein, we report a case of a previously well 11-year-old girl who presented with acute otitis media that progressed to mastoiditis and fulminant meningitis. Group A Streptococcus was found in blood and ear-fluid cultures (lumbar puncture was unsuccessful). Her decreased level of consciousness persisted despite appropriate antimicrobial treatment, and repeat MRI revealed extensive large vessel cerebral vasculitis. Based on expert opinion and a presumed inflammatory mechanism, her cerebral vasculitis was treated with 7 days of pulse intravenous methylprednisolone followed by oral prednisone taper. She was also treated with intravenous heparin. Following these therapies, she improved clinically and radiographically with no adverse events. She continues to undergo rehabilitation with improvement.

Successful Treatment of Massive Pulmonary and Venous Thromboembolism with Intravenous Heparin in a Patient with Mild Membranous Nephropathy.

Membranous nephropathy is well described to be associated with hypercoagulable state. Pulmonary embolism is a common occurrence with hypercoagulability and early recognition and prompt treatment including thrombolysis is warranted. We present here a case of massive thrombus in the pulmonary trunk and inferior vena cava in a patient with membranous nephropathy where anticoagulation with heparin was continued with successful resolution over time. We discuss the pros and cons of anticoagulation amangement in such patients and review the literature.