RESUMO
BACKGROUND: Patients who present with problems with definitive dialysis access (arteriovenous fistula (AVF) or arteriovenous graft (AVG)) become catheter dependent (temporary access), a condition that often carries a higher risk of infections, central venous occlusions and recurrent hospitalisations. For AVG, primary patency rates are reported to be 30% to 90% in patients undergoing thrombectomy or thrombolysis. According to the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines, surgery is preferred when the cause of the thrombosis is a stenosis at the site of the anastomosis in thrombosed AVF. The European Best Practice Guidelines (EBPG) reported that thrombosed AVF may be preferably treated with endovascular techniques, but when the cause of thrombosis is in the anastomosis, surgery provides better results with re-anastomosis. Therefore, there is a need to carry out a systematic review to determine the effectiveness and safety of the intervention for thrombosed fistulae. OBJECTIVES: This review aims to establish the efficacy and safety of interventions for failed AVF and AVG in patients receiving haemodialysis (HD). SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 28 January 2024 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Portal (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: The review included randomised controlled trials (RCTs) and quasi-RCTs in people undergoing HD treatment using AVF or AVG presenting with clinical or haemodynamic evidence of thrombosis. Patients had to have used an AVF or AVG at least once. DATA COLLECTION AND ANALYSIS: Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: Our search strategy identified 14 eligible studies (1176 randomised participants) for inclusion in this review. We included three types of interventions for the treatment of thrombosed AVF and AVG: (1) types of thrombectomy, (2) types of thrombolysis and (3) surgical procedures. Most of the included studies had a high risk of bias due to a poor study design, a low number of patients and industry involvement. Overall, there was insufficient evidence to suggest that a specific intervention was better than another for the outcomes of failure, primary patency at 30 days, technical success and adverse events (both major and minor). Primary patency at 30 days may improve with surgical compared to mechanical thrombectomy (3 studies, 404 participants: RR 1.36, 95% CI 1.07 to 1.67); however, the evidence is very uncertain. Death, access dysfunction, successful dialysis, and SONG (Standards Outcomes in Nephrology) outcomes were rarely reported. The current review is limited by the small number of available studies with a limited number of patients enrolled. Most of the studies included in this review have a high risk of bias and a low or very low certainty of evidence. Further research is required to define the most effective and clinically appropriate technique for access dysfunction. AUTHORS' CONCLUSIONS: It remains unclear whether any intervention therapy affects the patency at 30 days or failure in any thrombosed HD AV access (very low certainty of evidence). Future research will very likely change the evidence base. Based on the importance of HD access to these patients, future studies of these interventions among people receiving HD should be a priority.
Assuntos
Derivação Arteriovenosa Cirúrgica , Ensaios Clínicos Controlados Aleatórios como Assunto , Diálise Renal , Trombectomia , Trombose , Grau de Desobstrução Vascular , Humanos , Trombose/etiologia , Trombose/terapia , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Trombectomia/métodos , Trombectomia/efeitos adversos , Oclusão de Enxerto Vascular/terapia , Oclusão de Enxerto Vascular/etiologia , Terapia Trombolítica/métodosRESUMO
A hipoplasia da veia cava inferior é uma patologia rara que integra o conjunto de anomalias do desenvolvimento da veia cava inferior. A sua incidência situa-se entre 0,3%-0,5% na população saudável e 5% nos adultos jovens sem fatores de risco para trombose venosa profunda, sendo considerada um importante fator de risco para o desenvolvimento de trombose dos membros inferiores. O principal objetivo deste trabalho é reportar a conduta obstétrica de um caso clínico de uma grávida diagnosticada com hipoplasia da veia cava inferior, prévia à gravidez. Trata-se de um caso clínico, de uma grávida, primigesta, com 37 anos, com hipoplasia da veia cava inferior e heterozigotia para o gene MTHFR677 diagnosticadas, na sequência de uma trombose venosa bilateral dos membros inferiores e do segmento infrarrenal da veia cava inferior. A gravidez foi seguida em consulta hospitalar na nossa instituição, tendo a grávida sido medicada com enoxaparina em dose profilática e ácido acetilsalicílico, com um período pré natal que decorreu sem intercorrências. Às 37 semanas e 6 dias de gestação, deu entrada no Serviço de Urgência de Obstetrícia por rotura prematura de membranas. Intraparto foram utilizadas meias de compressão pneumática intermitente, tendo o parto ocorrido às 38 semanas de gestação por via vaginal (parto eutócico), do qual nasceu um recém-nascido do sexo feminino, com 2620g e índice de Apgar 9/10/10. O presente caso clínico demonstra que em situações de hipoplasia da veia cava inferior com um seguimento obstétrico adequado é possível a realização de um parto vaginal, possibilitando um desfecho obstétrico favorável (AU).
Hypoplasia of the inferior vena cava is a rare condition that belongs to the group of developmental anomalies of the inferior vena cava. It has an incidence between 0.3% and 0.5% in the healthy population and 5% in young adults without risk factors for deep venous thrombosis, being considered an important risk factor for the development of lower limb thrombosis. This study aims to report the obstetric conduct of a clinical case of a pregnant woman diagnosed with hypoplasia of the inferior vena cava prior to pregnancy. This is a clinical case of a pregnant woman, primigravid 37 years old, with hypoplasia of the inferior vena cava and heterozygosity for MTHFR677, diagnosed following a bilateral venous thrombosis of the lower limbs and the infrarenal segment of the inferior vena cava. The pregnancy was followed up in our institution. The pregnant woman was medicated with a prophylatic dose of low molecular weight heparin and acetylsalicylic acid with an uneventful prenatal period. At 37 weeks and 6 days of gestation, she was admitted to the Obstetrics Emergency Service due to premature rupture of membranes. Intermittent pneumatic compression sockings were used intrapartum, and at 38 weeks of gestation, a female newborn was vaginally delivered (eutocic delivery) with 2620g and an Apgar score of 9/10/10. The present clinical case demonstrates that in situations of hypoplasia of the inferior vena cava with an adequate obstetric follow-up, it is possible to perform a vaginal delivery, enabling a favourable obstetric outcome (AU).
Assuntos
Humanos , Feminino , Gravidez , Adulto , Trombose/terapia , Veia Cava Inferior/anormalidades , Conhecimentos, Atitudes e Prática em Saúde , PartoRESUMO
Objetivo: Identificar e analisar a qualidade das evidências científicas sobre a eficácia e segurança dos anticoagulantes orais direto (DOAC) disponíveis nos ensaios clínicos referenciados nas bulas dos medicamentos comercializados no Brasil. Método: Trata-se de um descritivo documental dividido em duas etapas, sendo elas: (i) identificação e análise da disponibilidade das referências bibliográficas contidas nas bulas dos DOAC e (ii) análise da qualidade dos estudos contidos nas bulas através da ferramenta da Cochrane Risk of Bias RevMan versão 5.4. Foram analisados setes domínios de importâncias para ensino clínico, sendo que cada domínio foi classificado como alto, incerto ou baixo risco de viés, segundo a avaliação dos colaboradores. Resultados: Foram analisadas 10 bulas destinadas aos profissionais da saúde. Sendo que destas, foram avaliados 25 ensaios clínicos. A análise da qualidade das evidências científicas, referenciadas nas bulas para profissionais dos DOAC, mostrou que os estudos citados apresentaram consistência metodológica. Entretanto, na maioria dos estudos, os domínios foram classificados como viés incerto, ou seja, não foi possível identificar como esses pontos foram abordados nos estudos. Conclusão: Portanto, o presente estudo evidenciou que a qualidade dos ensaios clínicos referenciados nas bulas dos DOAC apresentou incertezas metodológicas em seus ensaios. Sugere-se a necessidade de normativas que estabeleçam atualizações do conteúdo informativo presente nas bulas profissionais e estabeleçam descrição dos métodos de forma clara e coesa (AU).
Objective: Identify and analyze the quality of scientific evidence on the efficacy and safety of direct oral anticoagulants (DOAC) available in clinical trials referenced in the package leaflets of drugs marketed in Brazil. Method: This is a descriptive documentary study divided into two stages: (i) identification and analysis of the availability of the bibliographic references contained in the package leaflets of DOACs and (ii) analysis of the quality of the studies contained in the package leaflets through the Cochrane Risk of Bias RevMan tool version 5.4. Seven domains of importance for clinical teaching were analyzed, and each domain was classified as high, uncertain or low risk of bias, according to the assessment of the collaborators. Results: Ten package leaflets intended for health professionals were analyzed. Of these, 25 clinical trials were evaluated. The analysis of the quality of the scientific evidence referenced in the package leaflets for health professionals showed that the cited studies presented methodological consistency. However, in most studies, the domains were classified as uncertain bias, i.e., it was not possible to identify how these points were addressed in the studies. Conclusion: Therefore, the present study evidenced that the quality of clinical trials referenced in the package leaflets of DOACs presented methodological uncertainties in their trials. It is suggested the need for regulations that establish updates of the information content present in the professional package inserts and establish a description of the methods in a clear and cohesive way (AU).
Assuntos
Trombose/terapia , Viés , Bulas de Medicamentos , AnticoagulantesRESUMO
INTRODUCTION: Left ventricular assist devices are an established therapy for end-stage heart failure. Follow-up of these patients showed complications, such as thrombosis. Our objective was to evaluate the contribution of echocardiography - in association with HeartWare HVAD online logfiles reviews and lactate dehydrogenase titration - for diagnosis and treatment of thrombosis. METHODS: Seventeen episodes of thrombosis were diagnosed in 8/20 patients with HVAD. Diagnosis was made by trans-thoracic echocardiographic blood flow velocities, logfiles review of power consumption and pump flows, and titration of lactate dehydrogenase. Data were collected at baseline routine control (Group A), during thrombosis (Group B), after thrombolysis (Group C). RESULTS: Thrombolysis was successful in all cases; one patient died of cerebral haemorrhage. Echocardiographic maximal blood flow velocity near the inflow cannula was 598±42 cm/sec (Group B), 379.41±21 cm/sec (Group C), and 378.24±28 cm/sec (Group A) (P<0.00001). In eight (47%) cases, thrombi were visualized in the left ventricle by three-dimensional modality. Logfiles recordings of blood flows were 9.52±0.9 L/min (Group B), 4.02±0.4 L/min (Group C), and 4.04±0.4 L/min (Group A) (P<00001). Power consumption was 5.01±0.7 W (Group B), 3.45±0.2 W (Group C), and 3.46±0.2 W (Group A) (P<0.00001). Lactate dehydrogenase was 756±54 IU (Group B), 234±22 IU (Group A), and 257±36 IU (Group C) (P<0.00001). CONCLUSIONS: Echocardiography of increased maximal velocity near the inflow cannula is a sign of HVAD obstruction. Logfile reviews provide a clear picture of HVAD obstruction. Combination of echocardiographic data and review of logfiles detects signs of left ventricular assist devices thrombosis leading to a successful treatment.
Assuntos
Insuficiência Cardíaca , Coração Auxiliar , Trombose , Ecocardiografia , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/terapia , Coração Auxiliar/efeitos adversos , Humanos , Lactato Desidrogenases , Estudos Retrospectivos , Trombose/diagnóstico por imagem , Trombose/etiologia , Trombose/terapiaRESUMO
Thromboinflammation is a still not well-understood phenomenon, which has recently come to the foreground as a function of its relevance in the pathophysiology of coronavirus disease 2019 (COVID-19). The patient described in the present case report exhibited acute fever, giant urticaria, elevated acute phase reactants, and very high d-dimer levels, thus characterizing thromboinflammation. She was diagnosed as a COVID-19 suspect case, which was not confirmed; urticarial vasculitis was ruled out. Homeopathic treatment was started with the earliest clinical manifestations, resulting in rapid and drastic reduction of inflammation and hypercoagulability within the first 12 hours, and full recovery on 10-day follow-up assessment. This case demonstrates the effectiveness of homeopathy in a severe acute disorder, and points to the need to include laboratory testing in homeopathic clinical assessment to achieve an accurate picture of disease, and to avoid the risk of passing over life-threatening disorders.
Assuntos
Venenos de Abelha/uso terapêutico , Abelhas , COVID-19/complicações , Homeopatia , Inflamação/terapia , Trombose/terapia , Idoso , Animais , Proteína C-Reativa/análise , Feminino , Febre/virologia , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Inflamação/virologia , Trombose/virologia , Urticária/virologiaRESUMO
Coagulopathy and thrombosis associated with coronavirus disease 2019 (COVID-19) represent a major issue in the management of this disease. In the past months, clinical studies have demonstrated that COVID-19 patients present with a particular hypercoagulable state, in which a markedly increased D-dimer concomitant with increased levels of fibrinogen are observed. This hypercoagulable state leads to an increased risk of thrombosis, which seems to be higher among those patients with critical symptoms of COVID-19. The best therapeutic approach to prevent thrombotic events in COVID-19 has not been determined yet and several questions regarding thromboprophylaxis therapy, such as the time to initiate anticoagulation, type of anticoagulant and dose regimen, have emerged among physicians. To address these concerns, several medical societies have published position papers to provide the opinion of thrombosis experts on the management of coagulopathy and thrombosis associated with COVID-19. In line with this, the Latin America Cooperative Group of Hemostasis and Thrombosis (Grupo CLAHT) has constituted a panel of experts in thrombosis and hemostasis to discuss the available data on this topic. The aim of this review is to summarize the current evidence regarding hemostatic impairment and thrombotic risk in COVID-19 and to provide a carefully revised opinion of Latin American experts on the thromboprophylaxis and management of thrombotic events and coagulopathy in patients with suspected COVID-19.
La coagulopatía y la trombosis asociadas a la enfermedad por coronavirus 2019 (COVID-19) representan un problema importante en el manejo de esta enfermedad. Los estudios clínicos de los últimos meses han demostrado que los pacientes con COVID-19 presentan un estado de hipercoagulabilidad particular, en el que se observa un aumento notable del dímero D concomitante con niveles elevados de fibrinógeno. El estado de hipercoagulabilidad conduce a un mayor riesgo de trombosis, que parece ser mayor entre aquellos pacientes con síntomas críticos de COVID-19. El mejor enfoque terapéutico para prevenir los eventos trombóticos en esta nueva enfermedad aún no se ha determinado y han surgido varias preguntas con respecto a la tromboprofilaxia, como el momento adecuado para iniciar la anticoagulación, el tipo de anticoagulante y el régimen de dosis. Para abordar estas preocupaciones, varias sociedades médicas han publicado artículos de posición para brindar la opinión de expertos en trombosis sobre el manejo de la coagulopatía y trombosis asociadas a COVID-19. Grupo Cooperativo Latinoamericano de Hemostasia y Trombosis (Grupo CLAHT) ha convocado a un panel de expertos en trombosis y hemostasia para discutir los datos disponibles sobre este tema. El objetivo de esta revisión es resumir la evidencia actual con respecto al deterioro hemostático y el riesgo trombótico en el COVID-19 y proporcionar una opinión cuidadosamente revisada de los expertos latinoamericanos sobre la tromboprofilaxis y el manejo de eventos trombóticos y coagulopatía en pacientes con sospecha de COVID-19.
Assuntos
Anticoagulantes/uso terapêutico , COVID-19 , Trombose , Tromboembolia Venosa , COVID-19/complicações , Consenso , Hemostasia , Humanos , América Latina , Trombose/prevenção & controle , Trombose/terapia , Tromboembolia Venosa/prevenção & controle , Tromboembolia Venosa/terapiaAssuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Inflamação/virologia , Pneumonia Viral/complicações , Trombose/virologia , Tromboembolia Venosa/virologia , COVID-19 , Teste para COVID-19 , Técnicas de Laboratório Clínico , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/imunologia , Infecções por Coronavirus/terapia , Humanos , Inflamação/diagnóstico , Inflamação/imunologia , Inflamação/terapia , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/imunologia , Pneumonia Viral/terapia , SARS-CoV-2 , Trombose/diagnóstico , Trombose/imunologia , Trombose/terapia , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/imunologia , Tromboembolia Venosa/terapiaRESUMO
Arterial thromboembolism (ATE) is an acute and severe clinical condition resulting from the formation of a thrombus and its accommodation in an artery, impairing the perfusion of tissues irrigated by it. In felines, it is often related to hypertrophic cardiomyopathy, but there are reports of its association with neoplasms. Ischemia and reperfusion syndrome may occur secondary to ATE and result in difficult to correct electrolyte and acid-base imbalances. The aim of the present study is to describe a case of ATE, including its clinical and laboratory findings and electrolyte and acid-base changes compatible with ischemia and reperfusion syndrome. A 14-year-old crossbreed female feline with sudden pelvic limb paralysis was treated at the Feline Medicine Service of the Federal University of Rio Grande do Sul. Clinical and laboratory alterations included hypothermia, hypotension, bradycardia, azotemia, metabolic acidosis, and hyperkalemia. The electrocardiogram indicated sinoventricular rhythm, and echocardiogram evaluation showed no alterations. Thorax radiographic evaluation revealed areas of higher radiopacity in the pulmonary fields. We opted for abdominal aorta arteriotomy as an emergency treatment for thrombus removal. The feline died in the postoperative period, and histopathological examination of lungs, mediastinal lymph nodes, and heart were performed, being compatible with pulmonary adenocarcinoma with lymph node metastasis. This study deals with a case of ATE of possible neoplastic origin, which is uncommon in cats. In this case, the patient had difficult-to-manage hemodynamic impairment, as well as electrolyte and acid-base balance disorders severe and refractory to therapy, culminating in death. The time to start treatment from the presentation of clinical signs may be determinant in therapeutic success, reducing the possible effects of reperfusion syndrome.(AU)
O tromboembolismo arterial (TEA) é uma condição clínica aguda e grave decorrente da formação de um trombo e seu alojamento em uma artéria, prejudicando a perfusão dos tecidos irrigados por ela. Em felinos, está frequentemente relacionado com a cardiomiopatia hipertrófica, porém existem relatos da sua associação com neoplasias. A síndrome de isquemia e reperfusão pode ocorrer secundária ao TEA e resultar em desequilíbrios eletrolíticos e ácido-base de difícil correção. O objetivo do presente trabalho é descrever um caso de TEA, incluindo seus achados clínico-laboratoriais e as alterações eletrolíticas e acidobásicas compatíveis com a síndrome de isquemia e reperfusão. Foi atendido no Serviço de Medicina de Felinos da Universidade Federal do Rio Grande do Sul um felino, sem raça definida (S.R.D.), fêmea, de 14 anos de idade, com paralisia súbita dos membros pélvicos. As alterações clínicas e laboratoriais incluíram hipotermia, hipotensão, bradicardia, azotemia, acidose metabólica e hipercalemia. O eletrocardiograma indicou ritmo sinoventricular e a avaliação do ecocardiograma não mostrou alterações. A avaliação radiográfica do tórax revelou áreas de maior radiopacidade nos campos pulmonares. Optou-se pela arteriotomia da aorta abdominal como tratamento emergencial para a retirada do trombo. O felino veio a óbito no pós-operatório e foi realizado exame histopatológico dos pulmões, linfonodos mediastinais e do coração, que foi compatível com adenocarcinoma pulmonar com metástase para o linfonodo. O presente trabalho trata de um caso de TEA de possível origem neoplásica, o que é pouco comum em gatos. Neste caso, o paciente apresentou comprometimento hemodinâmico de difícil manejo, além de desordens eletrolíticas e do equilíbrio ácido-base graves e refratárias a terapia, culminando em óbito. O tempo do início do tratamento a partir da apresentação dos sinais clínicos pode ser determinante no sucesso terapêutico, reduzindo os...(AU)
Assuntos
Animais , Gatos , Tromboembolia/veterinária , Tromboembolia/terapia , Isquemia/veterinária , Reperfusão/veterinária , Trombose/veterinária , Trombose/terapiaRESUMO
BACKGROUND: Veno-venous extracorporeal membrane oxygenation is an established therapy for patients with refractory acute respiratory distress syndrome (ARDS). One complication related to the use of veno-venous extracorporeal membrane oxygenation is thrombosis despite proper anticoagulation. We report the diagnosis and management of a clot-obstruction in a single site cannula placed through the internal jugular vein, guided by transesophageal echocardiography. CASE REPORT: A 39 year-old male developed acute respiratory distress syndrome and hemodynamic instability after an episode of pulmonary aspiration in the ICU. Eight hours after placement of a single site veno-venous extracorporeal membrane oxygenation, suddenly the perfusionist noticed a reduction in flow. TEE showed a thrombus-like mass obstructing the inflow port in SVC and inflow at IVC was intact. After unsuccessful attempts to reposition the cannula, the team decided to insert additional femoral inflow cannula through the IVC. The single site catheter was then pulled out until its tip was positioned in the right atrium and all three ports of the catheter were switched to the infusion ports. After this, flows and oxygenation improved significantly. Unfortunately, despite all of the efforts, the patient died 2 days later. DISCUSSION: The diagnosis of veno-venous extracorporeal membrane oxygenation cannula obstruction is based on reduced inflow rates, hemodynamic instability and poor oxygenation of blood. TEE allows evaluation of the flows inside the cannula and in this case, an obstruction was found. The management presented points to the fact that in a situation of catheter obstruction caused by a clot, there is a feasible alternative to assure minimal interruption of the hemodynamic support offered by the veno-venous extracorporeal membrane oxygenation.