phenprocoumon and Ischemia

The purpose of this study was to determine the optimal intensity of oral anticoagulation in patients who participated in a randomized trial of oral anticoagulants or aspirin after infrainguinal bypass graft surgery.. The distribution of patient-time spent in international normalized ratio (INR) classes of 0.5 INR unit was calculated assuming a linear change between successive measurements. INR-specific incidence rates of ischemic and hemorrhagic events were calculated as the ratio of the number of events at a certain INR category and the total patient-time spent in that class. The relationship between INR class and event rates was quantified by rate ratios calculated in a Poisson regression model.. In 1326 patients (mean age, 69 years) 41,928 INR measurements were recorded in 1698 patient-years. Patients spent 50% of the total time within the target range of 3.0 to 4.5 INR. Most of the patient-time (60%) was spent between 2.5 and 3.5 INR. For each increasing class of 0.5 INR, the incidence of ischemic events (n = 154, INR data on event available in 49%) decreased by a factor of 0.97 (95% CI, 0.87-1.08). The incidence of major bleeding (n = 123, INR data on event available in 65%) increased significantly by a factor of 1.27 (95% CI, 1.19-1.34) for each increasing 0.5 INR category. The optimal target range was 3.0 to 4.0 INR, with an incidence of 3.8 events (0.9 ischemic and 2.9 hemorrhagic) per 100 patient-years.. The target range of 3.0 to 4.0 INR is the optimal range of achieved anticoagulation intensity and is safe for the prevention of ischemic events in patients after infrainguinal bypass graft surgery.

Topics: Acenocoumarol; Adult; Aged; Aged, 80 and over; Aspirin; Blood Vessel Prosthesis Implantation; Female; Graft Occlusion, Vascular; Hemorrhage; Humans; International Normalized Ratio; Ischemia; Leg; Male; Middle Aged; Netherlands; Phenprocoumon; Treatment Outcome

Topics: Aged; Anticoagulants; Atrial Fibrillation; Embolism; Emergencies; Heparin; Humans; Ischemia; Leg; Male; Patient Admission; Phenprocoumon; Treatment Refusal

Pedal bypass failure is not always associated with limb loss. Management of critical limb ischemia after failure is controversial. The aim of this study is to evaluate the results of redo bypass procedures to foot arteries in the absence of alternative tibial outflow arteries. Data of patients undergoing redo pedal bypass within a 14-year period were reviewed. The outcome after redo pedal bypass in patients whose original pedal bypass failed within 30 days versus those in patients whose original pedal bypass failed more than 30 days after the original pedal bypass were reviewed. Society for Vascular Surgery reporting standards were applied. Out of 335 pedal bypass grafts, 22 (6.6%) pedal redo bypass procedures were identified in 20 patients performed after previous pedal graft failure: 64% were male, mean age 67.7 +/- 9.5 years, diabetes 90.9%, hypertension 90.9%, coronary disease 68.2%, renal disease 18.2%. Seven patients were operated for early failure and 15 for late failure (median 193 days). The graft conduit at the first operation was ipsilateral greater saphenous vein (GSV) in 18 (81.8%), alternative vein in three (13.6%), and one expanded polytetrafluoroethylene. Redo graft conduits were as follows: ipsilateral GSV in nine (40.9%), arm vein in six (27.3%), contralateral GSV in two (9.1%), "other veins" in two (9.1%), and homologous artery in three (13.6%). The same target artery was used in 81.8%, at the initial site in 54.5% and more distally in 27.3%. Redo revascularization for early failure was successful only once. Median follow-up after late redo was 23.7 months. Seven redo grafts performed after late pedal graft failure failed after a median of 115 days. The availability of adequate autologous conduit is the limiting factor for redo procedures. Lack of alternative outflow sites adds to the difficulty of target artery dissection. Redo pedal bypass surgery after early pedal bypass failure is associated with very poor patency and limb salvage. Acceptable patency and extension of limb salvage can be achieved with redo procedures for late pedal bypass failure.

Topics: Aged; Anastomosis, Surgical; Anticoagulants; Arteries; Aspirin; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Drug Therapy, Combination; Female; Fibrinolytic Agents; Foot; Humans; Ischemia; Kaplan-Meier Estimate; Limb Salvage; Male; Middle Aged; Phenprocoumon; Polytetrafluoroethylene; Prosthesis Design; Radiography; Recurrence; Registries; Reoperation; Retrospective Studies; Saphenous Vein; Time Factors; Treatment Failure; Vascular Patency

On the day before admission a 68-year-old woman had an acute episode of incomplete ischaemia of the left lower arm. She had no known heart disease and her general condition was unchanged. There were no palpable pulses in the cold and pale lower arm. Sensory and motor functions of the left hand were slightly impaired. Arterial embolisation was suspected.. The blood picture was normal, erythrocyte sedimentation rate 20/50 mm, C-reactive protein elevated to 7.0 mg/l. There was no evidence of clotting abnormality. The resting ECG showed normal sinus rhythm. Doppler ultrasound gave a systolic pressure of 80 mm Hg over the radial artery and 50 mm Hg over the ulnar artery, with a systemic systolic pressure of 140 mm Hg. No intracardiac thrombi were seen on echocardiography. Transoesophageal echocardiography revealed a 2 x 3 cm hypermobile mass in the distal aortic arch, most likely a thrombus as the source of the embolus. Contrast computed tomography and digital subtraction angiography also demonstrated the mass.. At first heparin (bolus of 5000 IU, then 1000 IU/h) was infused. One day after the diagnosis had been established thrombectomy of the aortic arch and embolectomy of the left brachial artery were performed without complication. The patient was discharged on the 15th post-operative day on a maintenance dose of phenprocoumon. Histological examination of the surgical specimen from the aorta showed a separating thrombus on an ulcerating atherosclerotic plaque.. The importance of the thoracic aorta as a source of emboli is often underestimated. Transoesophageal echocardiography is a reliable method to demonstrate aortic thrombi.

Topics: Aged; Anticoagulants; Aorta, Thoracic; Brachial Artery; Echocardiography, Transesophageal; Electrocardiography; Embolectomy; Female; Fibrinolytic Agents; Forearm; Heparin; Humans; Ischemia; Phenprocoumon; Pulse; Thrombectomy; Thromboembolism; Thrombosis; Tomography, X-Ray Computed

Protein S, a vitamin-K dependent glycoprotein is a cofactor of protein-C system, which acts as an inhibitor of the plasmatic coagulation. Protein-S congenital deficiency results in recurrent venous thromboses, atypical locations in portal and mesenteric veins are possible. In our patient the partial thrombosis of the portal vein was diagnosed by computed tomography and angiography. Small bowel ischaemia due to mesenteric vein thrombosis required segmental resection. Post-operatively the patient was heparinized and later phenprocoumon was applied to a long-term therapy.

Topics: Adult; Heparin; Humans; Intestine, Small; Ischemia; Male; Mesenteric Vascular Occlusion; Mesenteric Veins; Phenprocoumon; Portal Vein; Postoperative Care; Protein S Deficiency; Thrombosis; Tomography, X-Ray Computed

1051 extremities with arterial reconstruction and anticoagulant prophylaxis were followed for at least 15 to 25 years. The results as to patency rate were best in patients with anticoagulation permanently in the therapeutic range. Interruption of the prophylaxis led to occlusions in half of the patients, most within the first year. 42 bleeding complications occurred in 37 patients, 0.005 per treatment year, 0.002 gastrointestinal, 0.0004 cerebral, 0.0001 with fatal outcome. Most bleedings occurred within the first ten years, 0.6 per treatment year in the first, 0.38 between the third and the seventh year, reaching a steady level of 0.46 at twelve years. Prophylaxis after arterial reconstruction for peripheral arterial disease should be restricted to patients without contraindications, in whom an optimal anticoagulation can be achieved within the first year.

Topics: Arterial Occlusive Diseases; Combined Modality Therapy; Follow-Up Studies; Hemorrhage; Heparin; Humans; Ischemia; Leg; Long-Term Care; Phenprocoumon; Postoperative Care; Prothrombin Time

Topics: 4-Hydroxycoumarins; Enteritis; Gastrointestinal Hemorrhage; Humans; Intestine, Small; Ischemia; Male; Middle Aged; Phenprocoumon; Recurrence