warfarin and Aortic-Aneurysm

Within the context of endovascular aneurysm repair (EVAR), the role of anticoagulation therapy on endoleak development and subsequent reintervention is unclear with conflicting data in the literature. The hypothesis of this study is that long-term anticoagulation is associated with persistent type II endoleaks and failure of sac regression in patients undergoing endoluminal repair of intact infrarenal aortic aneurysm.. Retrospective cohort abstracted from the Vascular Quality Initiative index hospitalization and long-term follow-up datasets for EVAR (2003-2017) were included in the analysis. Patients not taking aspirin preoperatively and postoperatively were excluded. Patients taking anticoagulation and aspirin concomitantly (treatment) after the index procedure were compared against patients taking aspirin alone (control). Anticoagulation included warfarin and novel oral anticoagulants, including factor Xa inhibitors and direct thrombin inhibitors. One-to-one greedy matching using propensity scores was implemented to match patients. The primary end points were failure of aneurysm sac regression, sac expansion, risk of endoleak, and reintervention rate for endoleak at follow-up. Sac regression was defined as a decrease of at least 5 mm and sac expansion was defined as an increase of at least 5 mm.. There were 9004 patients who received ASA alone and 332 patients who received ASA and anticoagulation. Propensity scores were used to create 301 matching pairs to account for differences in baseline characteristics and comorbidities, including but not limited to age, sex, smoking, coronary artery disease, heart failure, and chronic kidney disease between the treatment and control groups. After adjusting for covariables anticoagulation use was independently associated with a significantly decreased abdominal aortic aneurysm sac regression (41.59% vs 58.41%; P = .001), but no statistically significant difference in sac expansion with long-term anticoagulation use (9.7% vs 4.9%; P = .056). There was increased risk of type II endoleaks (11.96% vs 6.31%; P = .023; relative risk, 1.89; 95% confidence interval, 1.11-3.23; P = .016), but no significant differences in type I, III, or indeterminate endoleaks. There was no statistical difference in 2-year reintervention rates (4.32% vs 2.66%; hazard ratio, 1.43; 95% confidence interval, 0.55-3.77; P = .461). There were no differences in any primary outcome between warfarin and novel oral anticoagulants.. These data demonstrate that long-term aspirin plus anticoagulation use is associated with a lack of aortic sac reduction and persistent type II endoleak, but not an increased risk for subsequent reintervention. Because prior studies have demonstrated that sac regression is a correlate of survival, these findings associating regression failure suggest a potential therapeutic failure for patients undergoing EVAR who also require long-term anticoagulation therapy. Although not a contraindication, long-term anticoagulation should be considered when counseling patients with a surgical indication aortic aneurysm.

Topics: Anticoagulants; Aortic Aneurysm; Aortic Aneurysm, Abdominal; Aspirin; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Humans; Retrospective Studies; Risk Factors; Treatment Outcome; Warfarin

Topics: Acute Disease; Anticoagulants; Aortic Aneurysm; Aortic Dissection; Aspirin; Blood Vessel Prosthesis Implantation; Coronary Angiography; Coronary Thrombosis; Heparin; Humans; Male; Middle Aged; Plastic Surgery Procedures; Platelet Aggregation Inhibitors; Postoperative Complications; Treatment Outcome; Warfarin

We describe a case in which uncontrolled chronic disseminated intravascular coagulation (DIC) caused by an aortic aneurysm that was exacerbated by chemotherapy for lung cancer, showed dramatic improvement when warfarin, which was being administered for atrial fibrillation, was replaced by rivaroxaban, a direct oral anticoagulant (DOAC). The present case is interesting because a DOAC was effective in treating DIC due to an aortic aneurysm, whereas warfarin, another oral anticoagulant, was ineffective. In controlling DIC, it is important to inhibit activated coagulation factors such as thrombin and activated factor X, rather than the coagulation factors, which act as substrates.

Topics: Aged; Anticoagulants; Antineoplastic Agents; Aortic Aneurysm; Atrial Fibrillation; Disseminated Intravascular Coagulation; Humans; Lung Neoplasms; Male; Rivaroxaban; Warfarin

Topics: Aged; Anticoagulants; Antifibrinolytic Agents; Aorta; Aortic Aneurysm; Aortic Dissection; Blood Coagulation Factors; Heparin; Humans; Jehovah's Witnesses; Male; Postoperative Hemorrhage; Tranexamic Acid; Warfarin

Aortic false aneurysm is life-threatening with high morbidity and mortality rates. Surgical treatment varies according to the pathologic process, infection status, and site of origin of the aneurysm. We presented a case of false aneurysm of the ascending aorta, developing after type A acute aortic dissection repair. The operation was performed with the use of deep hypothermia and circulatory arrest to avoid massive uncontrollable hemorrhage.

Topics: Acute Disease; Aneurysm, False; Anticoagulants; Aortic Aneurysm; Aortic Dissection; Aortography; Blood Vessel Prosthesis Implantation; Circulatory Arrest, Deep Hypothermia Induced; Debridement; Drug Overdose; Fatal Outcome; Humans; Intracranial Hemorrhages; Male; Middle Aged; Reoperation; Stroke; Suture Techniques; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

An 84-year-old male on oral steroids, coumadin and multiple antiplatelets for stented superficial femoral artery presented to our hospital with chest oppression. His CT scan showed cardiac tamponade with periaortic hematoma. At first, sealed rupture of aortic dissection with thrombosed false lumen was suspected. However, delayed enhancement view revealed extravasation of contrast agent, which appeared to drain into the pericardium or pericardial space. Emergency thoracotomy revealed normal aorta with several small spurting vessels of pulmonary side of the pericardium. To the best of our knowledge, this is the first reported case in the literature of a parietal pleural hematoma without known cause such as malignancy or hematologic disorders.

Topics: Aged, 80 and over; Aortic Aneurysm; Aortic Dissection; Cardiac Tamponade; Coronary Restenosis; Drug Therapy, Combination; Hematoma; Humans; Male; Platelet Aggregation Inhibitors; Steroids; Tomography, X-Ray Computed; Warfarin

Endoleak after endovascular aortic aneurysm repair (EVAR) can affect the durability of the repair and lead to continued sac expansion, rupture, and the need for further endovascular or open surgical interventions. The purpose of this study was to determine whether chronic anticoagulation therapy with warfarin is associated with an increased incidence of endoleak and thus increased need for reintervention after EVAR.. We reviewed the records of 401 consecutive patients who underwent EVAR at a single institution from 2003 until 2011. Patients on warfarin were compared with a control group not on warfarin. Primary endpoints included reintervention, defined as rupture, explant, or angiography; death from any cause; and a composite outcome of reintervention or death. The presence of an endoleak at last follow-up, identified by computed tomography or ultrasound scan, and increase of more than 5 mm in aneurysm sac size were secondary endpoints. Cox proportional hazards models were used to estimate the effect of warfarin use on the primary and secondary outcomes, controlling for age, gender, obesity, specific comorbidities, antiplatelet drugs, statin use, and urgency of EVAR.. Three hundred sixty-three patients with a median follow-up period of 29 months had sufficient data for analysis. Warfarin use was not associated with an increased risk of any of the primary endpoints. Controlling for covariates and length of observation via proportional hazards models, the effect of warfarin remained insignificant. It was found, however, on regression analysis, that adverse outcomes were more prevalent after emergency EVAR and in patients deemed unfit for open surgical repair.. Chronic oral anticoagulation does not appear to affect the incidence of endoleak after EVAR, nor does it impact the need for reintervention or degree of sac regression. We feel that warfarin may be safely used in post-EVAR patients. It appears that adverse long-term outcomes are more likely after emergency EVAR and in patients deemed unfit for open surgery.

Topics: Aged; Anticoagulants; Aortic Aneurysm; Aortic Rupture; Aortography; Blood Vessel Prosthesis Implantation; Drug Administration Schedule; Elective Surgical Procedures; Emergencies; Endoleak; Endovascular Procedures; Female; Humans; Incidence; Kaplan-Meier Estimate; Maine; Male; Multivariate Analysis; Predictive Value of Tests; Proportional Hazards Models; Reoperation; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography, Doppler, Duplex; Warfarin

Reversal of anticoagulation-induced bleeding in the perioperative period can be challenging, particularly with an unstable patient with a mechanical valve. We present a case of life-threatening bleeding successfully managed with a prothrombin complex concentrate as an alternative to fresh frozen plasma.

Topics: Anticoagulants; Aortic Aneurysm; Aortic Valve; Blood Coagulation; Blood Coagulation Factors; Coagulants; Drug Monitoring; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Middle Aged; Postoperative Hemorrhage; Treatment Outcome; Vascular Surgical Procedures; Warfarin

Topics: Aged; Alcohol Withdrawal Delirium; Anticoagulants; Aortic Aneurysm; Aortic Dissection; Aortic Valve Insufficiency; Atrial Fibrillation; Delayed Diagnosis; Diagnostic Errors; Dyspnea; Edema; Epilepsy, Tonic-Clonic; Fatal Outcome; Heart Failure; Heart Valve Prosthesis; Humans; Hypertension; Male; Postoperative Complications; Psychomotor Agitation; Tomography, X-Ray Computed; Warfarin

We describe three cases of consumptive coagulopathy caused by extensive thrombus formation in otherwise 'uncomplicated' aortic aneurysms. These cases demonstrate the importance of performing a coagulation screen in any patient presenting with thrombocytopenia who may have an aortic aneurysm. Effective therapy with low-dose heparin was demonstrated with subsequent haemostasis being maintained with warfarin.

Topics: Aged; Aged, 80 and over; Aortic Aneurysm; Blood Coagulation Tests; Disseminated Intravascular Coagulation; Female; Fibrinogen; Heparin; Humans; Male; Partial Thromboplastin Time; Prothrombin Time; Thrombocytopenia; Ultrasonography; Warfarin

Topics: Aged; Aorta, Abdominal; Aortic Aneurysm; Cardiomegaly; Coronary Disease; Heparin; Humans; Lung Diseases, Obstructive; Male; Pulmonary Embolism; Warfarin

Topics: Abdomen, Acute; Aorta, Abdominal; Aortic Aneurysm; Humans; Male; Middle Aged; Pain; Phlebography; Pulse; Rupture; Vena Cava, Inferior; Warfarin