thrombosis

Liver Transplantation is fraught with thrombo-hemorrhagic complications, due to the precarious hemostasis of the recipient, anhepatic conditions, and the release of hemostatic factors from the allograft. Disseminated intravascular coagulation and its “flat-line” variant are common causes of hemorrhage and thrombosis, and frequently force the clinician along with a delicate balance between hemorrhage and thrombosis. We present a case that highlights some of the more challenging diagnostic and management decisions in liver transplantation and presents a safe and carefully structured approach to hyperfibrinolysis in liver transplantation.

Background: Persistent contrast staining is highly associated with stent thrombosis. Case summary: A 75-year-old woman presented with new-onset effort angina. A coronary angiogram revealed a 90% blockage of the distal left main trunk (LMT) and a 99% blockage of the ostial left anterior descending coronary artery (LAD). A 3.0 × 18-mm CYPHER™ the stent had previously been implanted into the dominant proximal circumflex artery (LCx) in 2009 because of unstable angina. The patient developed pulseless ST elevation myocardial infarction after the withdrawal of antiplatelet therapy before a scheduled CABG. The patient recovered with VA-ECMO and PCI using aspiration thrombectomy and urgent CABG.Discussion: This case highlighted that a preoperative patient may develop thrombosis at a previous stent site with peri-stent contrast staining and withdrawal of an antiplatelet regimen in certain settings poses an imminent risk for preoperative deterioration. A bridging strategy using intravenous PY12 inhibitor before CABG should be considered in this setting. The revascularization strategy should be selected based on coronary anatomy, hemodynamic status and baseline risk for CABG. A hybrid revascularization approach should be considered in this patient population.

Spine degenerative surgeries are very common but carry multiple complications such as dural tears, CSF leak, pseudomeningocele and very rarely meningitis. Here we report such a case and discuss the possible causes, management and review of the literature.It’s a case of a 68-year-old man who underwent a posterior laminectomy that was complicated by a CSF leak and pseudomeningocele. Twelve days later the patient developed a severe bifrontal headache and then altered sensorium. CSF studies revealed severe meningitis with Pseudomonas stutzeri. It was multi-sensitive and after initiation of gram-negative coverage the patient markedly improved. However, the meningitis was further complicated by cerebral venous sinus thrombosis and he was also started on anticoagulation.Conclusion: Pseudomonas stutzeri has rarely been reported as a cause of meningitis and has never been reported post-laminectomy. Meningitis symptoms and signs could be obscured by the use of steroids in the postoperative period. Hence, it is of paramount importance to look for any subtle signs of infection in the postoperative period and question the use of high-dose steroids that could easily mask them.

Disruption to contrast agent supply chains for radiology investigations has become an additional consequence of the COVID-19 pandemic. Various recommendations, including dose reductions and choices of alternative agents, have been made to help account for this limited availability. This case demonstrated how two separate CT venograms with different contrast agents, undertaken on the same day for the same patient, yielded different results; venous thromboses were more prominent in the subsequent scan. Although there was some evidence of venous sinus thrombosis on the first scan, repeat imaging was required to further characterize the lesions identified. The case exemplifies the notion that diagnostic imaging should always be guided by a detailed history and examination. It also raises the discussion point of whether more strict or uniform protocols should be developed to facilitate contrast administration for radiology investigations. It is important that appropriate doses are always administered to maximize diagnostic yield.

Portal vein thrombosis (PVT) is a rare condition that may congest bowel venous drainage and cause mesenteric ischemia. In acute settings, gastrointestinal bleeding (GIB) is rare, and acute abdominal pain is the most common clinical presentation. A 24-year-old man who presented with acute abdominal pain and a single episode of hematemesis is reported. Workups revealed evidence of thrombosis in the portal vein, but upper endoscopy was incapable to detect the source of the bleeding. We discuss the possible scenarios for the GIB in this case and review similar reports in the literature.

COVID vaccination has been associated with serious disorders including thrombosis with thrombocytopenia syndrome (TTS), Guillain-Barré syndrome (GBS), and myocarditis. GBS has been reported in adults following COVID-19 infection and rarely following the COVID-19 vaccination. Post COVID vaccination GBS has been associated with prominent and early facial diplegia and quadriplegia. Extension of the COVID vaccination program to the pediatric age group of 5 to 17 years has exposed this population to the adverse effects of the vaccination. Only a few case reports of post-vaccination GBS have been reported in the pediatric age group without any data on the true prevalence. We report a case of a male in his early adolescence with GBS presenting as facial diplegia and rapid quadriplegia following the BECOV2D, (Corbevax) vaccination. Our case is the first case of GBS reported following BECOV2D, (Corbevax) vaccination and highlights the presentation with prominent and early diplegia, which is similar to the presentation in adults.

This case suggests that POEMS syndrome does present with a constellation of signs and symptoms that may lead a clinician to a multitude of other possible diagnoses. Diagnosis is often difficult and delayed. A good history and physical examination as well as a careful review of all workups are paramount in establishing this particular diagnosis. The major criteria of diagnostic for the syndrome are polyradiculoneuropathy, clonal plasma disorder, sclerotic bone lesions, the presence of Castleman disease, and elevated vascular endothelial growth factor. Minor features include organomegaly, extravascular volume overload, endocrinopathy, characteristic skin changes, papilledema, and thrombocytosis. The diagnosis is made with three of the major criteria, two of which must include polyradiculoneuropathy and clonal plasma cell disorder, and at least one of the minor criteria. In this article, we discuss the differential diagnosis and outline the clinical evaluation indicated.

Introduction: Permanent vascular access (arteriovenous fistula (AVF), arteriovenous graft (AVG)) is susceptible to acute events that reduce patency. The temporary central venous catheter (CVC) constitutes bridging therapy for primary vascular access dysfunction. The impact of “residence time” on the rate of dysfunction/thrombosis or infection remains to be explored.AIM: 1) To evaluate the impact of CVC residence time on outcomes (infection or Thrombosis/dysfunction) in consecutive temporary CVCs adjusted for the insertion site (upper site vs. lower site).2) To establish a cut-off resident time.Patients and methods: Seventeen prevalent hemodialysis patients with three consecutive CVCs are followed up prospectively in an observational study for a period equivalent to the permanence of the CVCs. The data is recorded at the beginning of the CVC time. The diagnosis of catheter-related bloodstream infection and thrombosis/dysfunction is made following the K-Doqi 2019 guidelines.Statistical analysis: Seventeen hemodialysis patients (51 CVCs) were included. The ‘CVC resident time’ of each individual patient ((i.e. βcoefficient (log-transformed)*AUC)) was determined using LMM and then inserted into multivariate Cox models to assess infection and dysfunction/thrombosis outcomes (Joint Models). The AUC was calculated at various baseline levels of CVC time (10th……50th percentile). The cut-off point for thrombosis in CVC time corresponds to the mean of the CVC time at the 30th percentile of all CVCs.Results: The CVC time is different for CVC’s site insertion and sequence. From the analysis of multivariate joint models, CVC resident time appears not to be significant for infection, but heterogenicity for the insertion site (ref3-4=upper site) is significant for the outcome of thrombosis/dysfunction. From the study of survival analysis, the free survival from outcomes by CVC site insertion appears to be significant for thrombosis/dysfunction. The average time of CVCs’ calculation at the 30th percentile is 14 days (cut-off).Conclusion: No tunneled hemodialysis Catheter (NTHC) residence time is considered not to be a risk factor for infection, but it represents a risk factor for lower access thrombosis. After the cut-off time of 14 days, the advantage of the higher NTHCs is lost.

Iatrogenic femoral pseudoaneurysms are a rare complication of transfemoral vascular access. We present a case of a 65-year-old woman with a mechanical mitral valve requiring warfarin, who developed a femoral pseudoaneurysm four days after cardiac catheterization with femoral access. The patient developed a 17 x 10 x 17 cm rectus sheath hematoma and was treated with ultrasound-guided thrombin injection. Anticoagulation was held for three days while the patient was monitored for further bleeding and later restarted based on shared decision-making, given the risk of valve thrombosis. There are few guidelines regarding the re-initiation of anticoagulation in high-risk bleeding patients with mechanical mitral valves. Non-invasive coronary computed tomography angiography should be considered in patients on anticoagulation who require non-emergent cardiac ischemic evaluation.

Background: High blood pressure and dyslipidemia are risk factors that begin silently and share many pathophysiological mechanisms of tissue damage.Aim: Draw attention to this binomial (Hypertension and dyslipidemia) that is highly prevalent in Mexico and is mainly responsible for the leading atherothrombotic process as a cause of death in Mexico and the world.Methods: Reflective analysis of the evidence accumulated in the last 20 years. We launch key messages and support why every hypertensive patient should be treated with a statin.Results: We call for awareness to measure lipid levels and blood pressure twice a year from the age of 20 and to detect these devastating nosological entities as soon as possible. We remove the myth that PCSK9 inhibitors as well as the small interfering RNA of its synthesis are only for familial dyslipidemia. Measurement of serum Lp(a) should be routine, especially if you have a history of your own and family cardiovascular events.Conclusion: We should be aware of the little impact that health strategies have had to stop the main cause of death in Mexico. Every hypertensive patient should receive a statin, even if their serum LDLc levels are apparently normal. The great challenge of optimal control of the population with hypertension and/or dyslipidemia continues. The small interfering RNA synthesis PCSK9 should also be considered when conventional therapies are not sufficient and this situation is not infrequent.

Stroke is a clinically defined syndrome of acute focal neurological deficit attributed to vascular injury (infarction, hemorrhage) of the central nervous system. Stroke is the second leading cause of death and disability worldwide. Stroke is not a single disease but can be caused by a wide range of risk factors, disease processes and mechanisms. Approximately 15% of strokes worldwide are the result of intracerebral hemorrhage, which can be deep (basal ganglia, brainstem), cerebellar or lobar. A minority (about 20%) of intracerebral hemorrhages are caused by macrovascular lesions (vascular malformations, aneurysms, cavernomas), venous sinus thrombosis or rarer causes.

Pulmonary Embolism (PE) can present with symptoms resembling pneumonia, creating a diagnostic challenge, particularly in patients with comorbidities. We report the case of a 67-year-old male who presented with cough, hemoptysis, shortness of breath, fever, and pedal edema. Initially diagnosed with consolidation based on chest X-ray findings, he was treated with antibiotics. However, persistent symptoms prompted further evaluation, leading to the diagnosis of PE with pulmonary infarction and deep vein thrombosis on computed tomography pulmonary angiography and Doppler ultrasound. This case highlights the need to consider PE in the differential diagnosis of consolidation, particularly in high-risk individuals, to avoid delays in appropriate management.

Left ventricular thrombus (LVT) is a life threatening complication following acute coronary syndromes but in modern era its incidence has reduced since the introduction of primary percutaneous intervention. LVT is associated with higher morbidity and mortality due to its thromboembolic events and major adverse cardiac events (MACE). This is a case report of 30-year-old male  who presented with acute abdomen and left ventricular thrombus. CECT abdomen revealed superior mesenteric artery (SMA) thrombosis and echocardiography revealed severe ventricular dysfunction (ejection fraction, EF<30%) with global hypokinesia and LVT. SMA thrombosis is fatal and if left unattended can lead to intestinal ischemia and gangrene, hence immediate intervention is warranted. This patient had undergone emergency laparotomy under general anesthesia for the resection of gangrenous jejunal segment with mucous fistula . This case report discusses perioperative management considerations in such cases.