warfarin and Ischemia

Peripheral vascular disease is the rarest vascular complication in systemic lupus erythematosus. Some theories propose that immune complexes may promote inflammation in the vessel, and disrupt it in a manner that may cause ischemia.. A 14-year-old Asian girl presented with intermittent claudication as the chief complaint followed by discoloration of her left big toe for 2 weeks prior to admission. Her medical history showed that 1 month prior to admission she had photosensitivity, rash, and arthralgia, with positive antinuclear antibody test, positive anti-double-stranded DNA test, positive anti-ribosomal protein P, and complement C4 (7.4 mg/dL); she was diagnosed as having systemic lupus erythematosus and started therapy. A local examination of her left toe showed black discoloration, low pulsation, localized tenderness, and decreased sensation. Laboratory results showed C-reactive protein of 1.16 mg/dL and D-dimer of 2.28 uG/mL. A computed tomography angiogram showed near total occlusion of her popliteal artery; critical limb ischemia was confirmed. Peripheral arteriography was performed with invasive strategy. After the procedure, the flow was improved to distal, but there was inflammation in the vessel, so we decided to stop the procedure because of the risk of dissection. Our patient was given atorvastatin and warfarin, and we maximized her systemic lupus erythematosus therapy with prednisone. There were two follow-ups. The first follow-up was 1 week after the procedure. Our patient attended her first follow-up at our out-patient department with no symptoms and improvement in her toe's discoloration; warfarin was stopped, and clopidogrel and cilostazol were added for thrombus prevention therapy, she was then scheduled for debridement. The second follow-up was done 2 months after the first follow-up and discoloration was improved. The third follow-up, 5 months after the second follow-up, showed improvement.. Critical limb ischemia is a rare complication of systemic lupus erythematosus that requires immediate treatment. Due to our limited resources, we improvised a strategy to achieve the best possible outcome in our patient by using a combination of invasive treatment and medication.

Topics: Adolescent; Anticoagulants; Endovascular Procedures; Female; Hallux Valgus; Humans; Immunosuppressive Agents; Intermittent Claudication; Ischemia; Lower Extremity; Lupus Erythematosus, Systemic; Treatment Outcome; Warfarin

Direct oral anticoagulants are being presented as alternatives to warfarin for preventing stroke in patients with atrial fibrillation. Yet direct comparative trials between these agents in prevention of acute limb ischemia (ALI) are unavailable so far.. To conduct an adjusted indirect comparison meta-analysis between direct oral agents for prevention of acute limb ischemia in atrial fibrillation.. We conducted a systematic literature review searching electronic databases (MEDLINE and Embase) and the Cochrane Library from January 1990 through November 2014. Two blinded investigators reviewed all potentially relevant articles in a parallel manner by using a priori defined criteria. To assess the long-term efficacy and safety of these agents, only randomized clinical trials (RCTs) with follow-up durations of >1 year were included. The primary efficacy outcome was the end point of acute limb ischemia and/or extremity embolism.. A total of 44,563 patients from three RCTs met criteria for inclusion. Patients randomized to direct oral anticoagulants had a non-significant decreased risk for acute limb ischemia (risk ratio [RR]: 0.57, 95% confidence interval [CI]: 0.26-1.2). In the analysis between agents, however, rivaroxaban significantly lowered the risk of ALI compared to warfarin (RR: 0.23, 95% CI: 0.064-0.82), apixaban (RR: 0.26, 95% CI: 0.081-0.83), and dabigatran (RR: 0.24, 95% CI: 0.077-0.83).. Significant differences in prevention of acute limb ischemia may exist between oral anticoagulant agents in patients with atrial fibrillation. Rivaroxaban lowers the risk of limb embolism versus warfarin, apixaban and dabigatran.

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Dabigatran; Embolism; Humans; Ischemia; Leg; Odds Ratio; Pyrazoles; Pyridones; Rivaroxaban; Stroke; Warfarin

Thromboembolic events in chronic inflammatory bowel diseases are rare and predominated by venous damage. Arterial thromboembolic events are extremely uncommon. We are reporting the case of a 50-year-old male patient with an 8-year history of ulcerative colitis, who presented a recurring severe lower limb ischemia during hospital stay for exacerbation of his inflammatory bowel disease. During the first visit, the patient underwent a balloon thromboembolectomy via femoral approach, with fasciotomy of the leg. Because of recurrence of symptoms, he underwent a second and a third thromboembolectomy by a popliteal approach, with an uneventful postoperative course and was discharged home 10 days later, on warfarin therapy and oral corticosteroids. After an extensive literature review using PubMed, we found 20 reported cases in the English literature over the past 25 years; not including this present case. In the absence of major cardiovascular risk factors, inherited thrombophilia and intracardiac thrombi, we consider active ulcerative colitis to be the major trigger of the embolic lower limb ischemia in our patient. By means of this report, we seek to create awareness of the increased risk of arterial thromboembolism in inflammatory bowel diseases patients.

Topics: Adrenal Cortex Hormones; Balloon Embolectomy; Colitis, Ulcerative; Humans; Ischemia; Lower Extremity; Male; Middle Aged; Thromboembolism; Warfarin

Thromboembolism is a severe complication in atrial fibrillation. This overview presents thromboembolic disease as a single entity, ranging from stroke through mesenteric ischemia to acute limb ischemia. The PubMed, Embase, and Cochrane databases were systematically searched for the terms "atrial fibrillation" and "thromboembolism" in reports published from January 1986 to September 2009. The information of 10 evidence-based practice guideline documents and 61 further sources was systematically extracted. In atrial fibrillation, the average annual stroke risk is increased by 2.3% (lethality 30%). The annual incidence of acute mesenteric ischemia is 0.14% (lethality 70%), and that of acute limb ischemia is 0.4% (lethality 16%). In total, approximately 80% of embolism-related deaths are from stroke and 20% from other systemic thromboembolism. The ischemic symptoms generally have an acute onset but may mimic other diseases, particularly in mesenteric ischemia. Early diagnosis and treatment can limit or even prevent tissue infarction. Guideline-recommended therapy with aspirin or warfarin reduces the thromboembolic risk. Suitable patients may optimize their warfarin therapy by self-monitoring of the international normalized ratio (INR). New oral and parenteral anticoagulants with more stable pharmacokinetics are being developed. In conclusion, atrial fibrillation predisposes to thromboembolism. If ischemic stroke or systemic thromboembolism occurs, early diagnosis and treatment can improve outcomes. The thromboembolic risks are reduced by guideline-adherent antithrombotic therapy with warfarin or aspirin. Future directions may include self-monitoring of the international normalized ratio and novel anticoagulants.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Atrial Fibrillation; Drug Therapy, Combination; Early Diagnosis; Evidence-Based Medicine; Germany; Humans; Incidence; Ischemia; Lower Extremity; Mesentery; Practice Guidelines as Topic; Stroke; Thromboembolism; Warfarin

Severe peripheral artery disease (PAD) is the predominant cause of ischemic ulcerations involving the lower extremities. PAD-associated ulcerations are typically distally located involving the feet, toes, and sometimes the calves. In contradistinction, atypical ischemic ulcerations of the lower extremity are often non-atherosclerotic in etiology, involve the proximal leg (thigh/buttocks), can evolve despite palpable distal pulses, and may coexist with other cutaneous aberrations (e.g. macules, purpura, nodules, and livedo reticularis). A differential diagnosis of atypical ischemic ulcerations involving the legs is presented.

Topics: Anticoagulants; Antiphospholipid Syndrome; Calciphylaxis; Diagnosis, Differential; Drug Eruptions; Embolism, Cholesterol; Heparin; Humans; Ischemia; Leg Ulcer; Lower Extremity; Peripheral Vascular Diseases; Spider Bites; Vasculitis; Warfarin

To review the rationale, clinical practice guideline recommendations, and clinical trial data describing bleeding and clinical outcomes associated with the use of the combination of aspirin, a thienopyridine, and warfarin.. An English-language literature search was conducted using MEDLINE (1966-March 2008) and the search terms aspirin, clopidogrel, ticlopidine, thienopyridine, warfarin, antiplatelet, anticoagulant, myocardial infarction, atrial fibrillation, and percutaneous coronary intervention (PCI). Additional references were identified by reviewing reference citations of articles retrieved.. Applicable data were extracted from published reports and studies that included either clinical outcomes or adverse events.. Clinical guidelines recommend the combination of antiplatelets and anticoagulants based largely on writing committee consensus. To date, only one randomized clinical trial has evaluated the safety and efficacy of adding warfarin to dual antiplatelet therapy (ie, triple antithrombotic therapy). Other published data are from case series, observational studies, and case-controlled studies primarily of patients undergoing PCI with intracoronary stent placement. Four of 12 studies reported no increased risk of major bleeding events. In the other 8 studies, a 3- to 6-fold increase in bleeding events was reported with triple antithrombotic therapy. Ischemic events were reported in only 6 of the studies. Only 2 studies observed an additional benefit in the reduction of ischemic events, and 1 study reported worsened ischemic outcomes with the triple antithrombotic regimen compared with dual antithrombotic therapy.. Available guidelines pertaining to the concomitant administration of aspirin, a thienopyridine, and warfarin are based on limited trial data and consensus judgment. Overall, selection of triple antithrombotic therapy for patients with vascular disease is considered a matter of clinical judgment for an individual patient based on the prescriber's perceived balance between the patient's risk for recurrent ischemic events, expected duration of treatment, and patient's risk for bleeding.

Topics: Anticoagulants; Aspirin; Clinical Trials as Topic; Clopidogrel; Drug Interactions; Drug Therapy, Combination; Hemorrhage; Humans; Ischemia; Platelet Aggregation Inhibitors; Practice Guidelines as Topic; Ticlopidine; Vascular Diseases; Warfarin

Stroke outcomes in patients with atrial fibrillation (AF) tend to be worse than those in patients without AF. The objective of this study was to evaluate whether the cost benefits of anticoagulation for stroke prevention in AF may currently be underestimated by existing economic models that do not distinguish between different stroke outcomes.. A literature review was conducted in 3 areas: (1) studies comparing stroke outcomes in AF and non-AF patients; (2) studies providing long-term cost of stroke estimates; and (3) studies modeling the cost-effectiveness of anticoagulation with a vitamin K antagonist (eg, warfarin) in AF patients.. There is considerable evidence that stroke in AF patients has a worse outcome than in patients without AF, including higher mortality, severity, and recurrence rates, and greater functional impairment and dependency. Estimates of the long-term cost of stroke of different severities were between US 24,991 dollars for a mild stroke over 5 years and US 142,251 dollars for a major ischemic stroke over a lifetime (2004 prices). The cost of a severe ischemic stroke may typically be 3-times that of mild stroke. However, cost-effectiveness models for anticoagulation in patients with AF have used average (not AF-specific) cost-of-stroke data, and most have used stroke severity distributions derived from clinical trials, which may differ from those in clinical practice.. Existing economic models underestimate the cost benefits of anticoagulation for stroke prevention because they do not adjust for poorer outcomes associated with cardioembolic strokes.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Brain Ischemia; Cerebrovascular Disorders; Clinical Trials as Topic; Cost-Benefit Analysis; Humans; Ischemia; MEDLINE; Middle Aged; Models, Theoretical; Multivariate Analysis; Quality-Adjusted Life Years; Risk Factors; Stroke; Time Factors; Treatment Outcome; Vitamin K; Warfarin

Recommendations for transitioning from therapy with heparin or a low-molecular-weight heparin preparation to therapy with an oral anticoagulant in patients with acute venous or arterial thromboembolism have undergone several changes during the last two decades. Physicians are now comfortable with beginning treatment with an oral anticoagulant once the diagnosis is confirmed, and loading doses are no longer considered to be necessary. Exceptions to early transition may be necessary in patients with an extensive iliofemoral or axillary-subclavian vein thrombosis or pulmonary embolism where thrombolytic agents may be indicated, or in individuals who require surgery or other invasive procedures, or if there are concerns about bleeding. The avoidance of early transition to oral anticoagulants in patients with acute heparin-induced thrombocytopenia also has been advised because of the potential for further thrombotic complications, including venous limb gangrene and warfarin-induced skin necrosis.

Topics: Administration, Oral; Anticoagulants; Arginine; Blood Coagulation; Blood Coagulation Factors; Chondroitin Sulfates; Dermatan Sulfate; Drug Combinations; Gangrene; Heparin; Heparitin Sulfate; Hirudins; Humans; Ischemia; Leg; Necrosis; Pipecolic Acids; Recombinant Proteins; Skin; Sulfonamides; Thrombocytopenia; Thrombosis; Warfarin

Warfarin is the best available, most effective treatment for the secondary prevention of recurrent thrombosis in antiphospholipid syndrome (APS) patients. However, warfarin is cumbersome for both patients and physicians because of risk for bleeding and the need for frequent monitoring. Much detail regarding optimal management of APS patients still lacks an evidence-based approach. Asymptomatic patients should not receive warfarin. An optimal treatment for patients with livedo, cardiac valve disease, leg ulcers or microangiopathic nephropathy is unknown; it is likely that warfarin is ineffective for these manifestations of the APS. In low risk patients who have not previously failed warfarin, moderate intensity anticoagulation (target international normalized ratio [INR] 2.5) is as effective as, and safer than, high intensity anticoagulation (INR 3.5), at least for patients with venous thrombosis. Current recommendations, based on the opinion rather than on documentation, state that warfarin should be prescribed for the APS patient's life; studies that challenge this conclusion for carefully defined low risk patients whose thromboses occurred with trigger events will be welcome, as will be studies examining alternatives to warfarin, including antiplatelet drugs.

Topics: Antibodies, Antiphospholipid; Anticoagulants; Antiphospholipid Syndrome; Female; Humans; Ischemia; Pregnancy; Thrombosis; Warfarin

Topics: Anticoagulants; Aortic Valve Insufficiency; Arginine; Autoantibodies; Autoimmune Diseases; Female; Fingers; Heart Valve Prosthesis Implantation; Heparin; Hirudins; Humans; Ischemia; Middle Aged; Necrosis; Pipecolic Acids; Platelet Activation; Platelet Factor 4; Postoperative Complications; Raynaud Disease; Recombinant Proteins; Sulfonamides; Thrombocytopenia; Thrombosis; Toes; Warfarin

The sudden development of cyanotic lesions on the feet may be a result of atheroembolic disease or a number of medical conditions. A careful history and physical examination, basic laboratory tests, and noninvasive vascular assessment usually distinguish between medical and surgical causes and direct the choice of further investigations. Specific therapy is often available for medical conditions causing this syndrome. The management of atheroembolic disease is more controversial. In particular, further research is necessary to determine which patients need surgical intervention and which patients can be managed safely by medical therapy.

Topics: Adrenal Cortex Hormones; Blood Coagulation Disorders; Calcinosis; Cyanosis; Embolism; Humans; Ischemia; Postoperative Complications; Skin Diseases; Syndrome; Toes; Vasculitis; Warfarin

Results of reconstructive operations, performed on the main arteries of the lower extremities (LE) in 63 patients, suffering obliterating atherosclerosis were analyzed with the objective to analyze the causes of thrombotic complications occurrence. There was established, that common clinical screening tests, applied for control of the hemostasis system state, do not permit completely to reveal thrombophylic changes in early postoperative period timely and to prevent the occurrence of the reconstructed segments thrombosis. Direct correlation connection between the ischemia stage of the LE tissues, the reperfusion changes signs and hyperaggregation severity, occurring due to deficiency of the blood serum natural anticoagulants in patients, suffering obliterating atherosclerosis, was established.

Topics: Aged; Anticoagulants; Arteriosclerosis Obliterans; Blood Coagulation; Enoxaparin; Female; Humans; Ischemia; Male; Microcirculation; Plastic Surgery Procedures; Postoperative Complications; Severity of Illness Index; Thrombosis; Treatment Outcome; Warfarin

We sought to compare the effects of clopidogrel combined with warfarin with clopidogrel alone in the prevention of restenosis after endovascular treatment (EVT) of the femoropopliteal artery.. Between June 2008 and May 2009, 88 consecutive patients referred for EVT were randomly divided into a clopidogrel group (42 cases) and a clopidogrel combined with warfarin group (46 cases) before the procedure. Examinations including staging of peripheral arterial disease by Rutherford, ankle-brachial index, and color duplex ultrasonography were performed at baseline, 1 week, 3 months, 6 months, and 12 months after procedure. At the same time, bleeding complications were observed.. Fifty patients (63 limbs) were included after 12 months of follow-up, in which 25 patients (30 limbs) were from the clopidogrel group and 25 patients (33 limbs) were from the combination group. At 3 months, the rates of restenosis on duplex ultrasonography were 17% in the clopidogrel group and 18% in the combination group (P = 1.0). At 6 months, the accumulated restenosis rates were 37% and 36% (P = 0.98), respectively. At 12 months, the accumulated restenosis rates were 53% and 42% (P = 0.523), respectively. The rate of clinical bleeding events was 21% (6/29) in the combination group compared with 7% (2/27) in the clopidogrel group, and there was no statistical difference (P = 0.3).. The combination of clopidogrel with warfarin was not more effective than clopidogrel alone in restenosis prevention for patients who underwent EVT. Instead, the combination of antiplatelet and anticoagulation therapy was inclined to increase the clinical bleeding events.

Topics: Aged; Anticoagulants; Clopidogrel; Constriction, Pathologic; Drug Therapy, Combination; Endovascular Procedures; Female; Femoral Artery; Humans; Ischemia; Male; Perioperative Care; Platelet Aggregation Inhibitors; Popliteal Artery; Recurrence; Ticlopidine; Warfarin

Poor patency of synthetic grafts for infragenicular revascularization has led to use of distal vein patches or cuffs. The aim of this study was to compare the distally widened Distaflo PTFE graft, which mimics a vein cuff, with a PTFE graft with distal vein modification. In this prospective, randomized, multicenter trial we compared use of a precuffed PTFE graft wit that of PTFE grafts with distal vein modification for infragenicular revascularization in patients with critical limb ischemia without saphenous vein. Study end points were primary and secondary patency and limb salvage rates at 2 years. From January 28,1999 to November 1, 2000, 104 patients were enrolled in 10 North American centers. Thirteen were excluded for protocol violation. Ninety-one bypasses were performed in 89 patients with a mean age of 73 years (range 47-90). By randomization, 47 bypasses were done with the precuffed graft and 44 with PTFE graft with vein cuff. Both groups were comparable for comorbidities and operative variables, except for a higher incidence of acute ischemia in the precuffed group (19% vs. 4.5%, p = 0.03). Bypass was a redo procedure in 53% and was performed at the infrapopliteal vessels in 79%. Operative mortality was 2.2% (2/91). Mean follow-up was 14 months (range 1-30). At 1 and 2 years, primary patency was 52% and 49% for the precuffed group and 62% and 44% for the vein cuffed group, respectively (p = 0.53). At 1 year and 2 years, the limb salvage rate was 72% and 65% for the precuffed group and 75% and 62% in the vein cuffed group (p = 0.88). Although numbers are small and follow-up short, this midterm analysis shows similar results for the Distaflo precuffed grafts and PTFE grafts with vein cuff. A precuffed graft is a reasonable alternative conduit for infragenicular reconstruction in the absence of saphenous vein and provides favorable limb salvage.

Topics: Aged; Aged, 80 and over; Anastomosis, Surgical; Anticoagulants; Arterial Occlusive Diseases; Aspirin; Blood Vessel Prosthesis; Female; Follow-Up Studies; Graft Occlusion, Vascular; Humans; Iliac Artery; Ischemia; Limb Salvage; Lower Extremity; Male; Middle Aged; Platelet Aggregation Inhibitors; Polytetrafluoroethylene; Popliteal Artery; Prospective Studies; Prosthesis Design; Reoperation; Tibial Arteries; Time Factors; Treatment Outcome; Vascular Patency; Warfarin

A recent retrospective study showed that the ischemic consequences of femoropopliteal bypass graft occlusion were more severe with polytetrafluoroethylene (PTFE) than with vein. This study examines this conclusion and whether oral anticoagulation therapy reduces the degree of ischemia after occlusion of PTFE and vein femoropopliteal bypass grafts.. Four hundred two patients who underwent femoropopliteal bypass grafting (233 PTFE and 169 vein) were randomized to a postoperative regimen of either warfarin (international normalized ratio, 1.4 to 2.8) and aspirin (WASA; 325 mg daily) therapy or aspirin alone (ASA) therapy. The grade of acute ischemia at the time of graft occlusion was assessed with the Society of Vascular Surgery recommended reporting standards (I, viable; II, threatened). Early graft occlusions (<30 days) were excluded.. There were 100 graft occlusions (67 PTFE and 33 vein) during a mean follow-up period of 36 months (PTFE) and 39 months (vein). Forty-eight patients were randomized to WASA therapy, and 52 were randomized to ASA therapy. The patients were well matched for age, atherosclerotic risk factors, operative indication, and preoperative ankle-brachial index. Overall, a greater percentage of the PTFE occlusions caused grade II ischemia than did the vein graft occlusions (48% versus 18%; P =.005). The ankle-brachial index at the time of graft occlusion was significantly lower in the PTFE grafts than in the vein grafts (0.28 versus 0.45; P =.001). The patients with PTFE who were undergoing WASA therapy at the time of graft occlusion had less grade II ischemia than did those patients who were undergoing ASA therapy (28% versus 55%; P =.057). However, the incidence rate of severe ischemia after graft occlusion remained greater with PTFE grafts and WASA therapy as compared with all the vein grafts (28% versus 18%). The vein graft occlusions had the same incidence rate of grade II ischemia with WASA therapy as with ASA therapy (20% versus 17%; P = 1.0).. The ischemic consequences of femoropopliteal bypass graft occlusion are worse with PTFE than with vein. Treatment with WASA therapy lessens the severity of acute ischemia after the occlusion of PTFE graft as compared with ASA therapy but not to the degree seen with vein graft occlusion. Occlusion of femoropopliteal vein grafts is seldom accompanied by severe ischemia and is not improved with WASA therapy.

Topics: Aged; Amputation, Surgical; Anticoagulants; Aspirin; Boston; Femoral Vein; Fibrinolytic Agents; Follow-Up Studies; Graft Occlusion, Vascular; Humans; Incidence; Intermittent Claudication; International Normalized Ratio; Ischemia; Leg; Maryland; Middle Aged; Polytetrafluoroethylene; Popliteal Vein; Prospective Studies; Severity of Illness Index; Texas; Treatment Outcome; Warfarin

This study demonstrates that niacin supplementation decreases plasma fibrinogen and low-density lipoprotein cholesterol in subjects with peripheral vascular disease randomized to receive niacin, warfarin, antioxidants, or placebo. Changes in fibrinogen levels are highly correlated with changes in low-density lipoprotein cholesterol (r = 0.61; p < 0.009) in subjects taking niacin.

Topics: Adult; Antioxidants; Arterial Occlusive Diseases; Cholesterol, HDL; Cholesterol, LDL; Dose-Response Relationship, Drug; Female; Fibrinogen; Hemodynamics; Humans; Hypolipidemic Agents; Ischemia; Leg; Male; Middle Aged; Niacin; Warfarin

We analyzed the short- and long-term results for patients undergoing thrombolysis of occluded infrainguinal bypass grafts at our institution over a 62-month period.. Thirty-one patients with 40 episodes of graft thrombosis in 33 grafts managed by thrombolysis were retrospectively reviewed. The effects of graft age, material, and anatomy, symptoms, treatment, anticoagulation, and occlusion duration were evaluated for impact on patency after thrombolysis. Dose and duration of therapy with use of the technique of pulse-spray thrombolysis was assessed.. Thrombolysis successfully reestablished patency in 92% of grafts treated. Mean lysis time and urokinase dose were 118 minutes and 607,000 units, respectively. Responsible lesions were identified and treated by angioplasty or surgery in 35 of 37 cases. The patency rate after thrombolysis was 28% at 30 months, and the secondary patency rate was 46% at 18 months. Duration of occlusion, symptoms, treatment, graft anatomy, and prior graft revision did not impact on patency. Mean secondary patency was 21.5 months in grafts in place over 1 year and 7.0 months in grafts in place for less than 1 year. Mean secondary patency was 23.8 months in polytetrafluoroethylene grafts and 8.4 months in vein grafts. The limb salvage rate was 84% at 30 months, and the patient survival rate was 84% at 42 months.. Pulse-spray thrombolysis is effective in rapidly recanalizing thrombosed infrainguinal grafts. Grafts failing in the first year after placement should generally be replaced, reserving thrombolysis and revision for grafts greater than 1 year old. Vein grafts tolerate thrombosis less well than synthetic conduits and have decreased long-term patency.

Topics: Adult; Aged; Angioplasty; Arteriovenous Shunt, Surgical; Combined Modality Therapy; Female; Follow-Up Studies; Graft Occlusion, Vascular; Humans; Intermittent Claudication; Ischemia; Leg; Life Tables; Male; Middle Aged; Polytetrafluoroethylene; Popliteal Vein; Prosthesis Failure; Recombinant Proteins; Reoperation; Retrospective Studies; Survival Rate; Thrombolytic Therapy; Tibial Arteries; Time Factors; Tissue Plasminogen Activator; Urokinase-Type Plasminogen Activator; Vascular Patency; Warfarin

Evidence of clinical outcomes for oral anticoagulants and antiplatelet treatment (APT) in patients with atrial fibrillation (AF) and critical limb ischemia (CLI) is very limited.. In this nationwide retrospective cohort study collected from Taiwan National Health Insurance Research Database, 1223 patients with AF and CLI taking direct-acting oral coagulants (DOACs), warfarin, or APT were identified from June 1, 2012, to December 31, 2017. We used propensity score stabilized weighting (PSSW) to balance covariates across study groups.. After PSSW, DOAC (n = 446) was associated with lower risks of ischemic stroke/systemic embolism (IS/SE), all major adverse limb events, and all major bleeding events compared with warfarin (n = 237). DOAC was associated with lower risks of IS/SE, acute myocardial infarction (AMI), and all major adverse limb events and a comparable risk of major bleeding events compared with APT (n = 540). DOAC has a lower risk of composite net-clinical-benefit outcome (IS/SE, AMI, all major adverse limb events, plus all major bleeding events) compared with warfarin (hazard ratio [HR]: 0.48; 95% confidence interval [CI]: 0.35-0.65; P < 0.0001) or APT (HR: 0.44; 95% CI: 0.34-0.56; P < 0.0001). The composite net-clinical-benefit outcome was comparable for warfarin vs APT. The reduced risk of net-clinical-benefit outcome for DOAC vs warfarin or APT persisted in high subgroups including age > 75 years, presence of diabetes mellitus, or chronic kidney disease.. DOAC was associated with a significantly lower risk of composite net-clinical-benefit outcome than either warfarin or APT in patients with AF and concomitant CLI. Further prospective study is necessary to validate the findings in the future.

Topics: Anticoagulants; Atrial Fibrillation; Cohort Studies; Embolism; Extremities; Factor Xa Inhibitors; Hemorrhage; Humans; Ischemia; Ischemic Stroke; Platelet Aggregation Inhibitors; Retrospective Studies; Taiwan; Warfarin

Acute upper limb ischemia is an uncommon clinical manifestation of thromboembolism seen predominantly in patients with atrial fibrillation. Treatment can be by conservative or surgical means but the consensus is that after conservative treatment, symptoms still persist. In this series, an attempt was made at limb preservation and return to functional capacity by early surgery in all patients diagnosed with acute limb ischemia.. Patients referred with upper limb ischemia (22) were stratified into non-acute (6) treated with anticoagulation alone and those with acute ischemia. Sixteen (16) patients, age range 30-92 years (median 62.4 years) comprising mainly females (13), had clinical evidence of severe ischemia and underwent immediate brachial embolectomy with postoperative anticoagulation.. Sixteen patients underwent 20 embolectomies with immediate reperfusion of limbs and relief of symptoms. Two patients had two re-operations each due to recurrent symptoms but both recovered with good outcome, one going on to have an axillary-radial bypass. There was no limb disability nor limb loss, but one postoperative mortality. All other patients were seen at their 1-year review and at 5 years, eleven out of 15 patients were still alive with most resuming an active lifestyle and some returning to work.. Good outcomes were obtained in this series in both the short and long term. Despite one mortality, there was no limb loss nor disability in a mainly elderly population. Prompt surgery and meticulous long-term anticoagulation reduced complications and improved limb salvage rates ensuring that patients had a good quality of life after surgery.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Embolectomy; Female; Humans; Ischemia; Limb Salvage; Male; Middle Aged; Quality of Life; Retrospective Studies; Time Factors; Treatment Outcome; Upper Extremity; Warfarin

Topics: Aged; Benzoates; Biopsy; Clopidogrel; Computed Tomography Angiography; Conservative Treatment; Female; Humans; Hydrazines; Hyperbaric Oxygenation; Ischemia; Platelet Count; Purpura, Thrombocytopenic, Idiopathic; Pyrazoles; Skin; Thrombosis; Tibial Arteries; Toes; Treatment Outcome; Warfarin

A 50-year-old woman with a history of Crohn's disease treated with adalimumab presented with left hand pain and duskiness. Angiogram showed non-filling of the radial and digital arteries of the hand. Antiphospholipid antibody testing was positive, leading to a diagnosis of antitumour necrosis factor-induced antiphospholipid syndrome. Adalimumab was discontinued, and she was treated with the vitamin K antagonist warfarin and low-dose aspirin. Upon resolution of the antiphospholipid antibodies, she was transitioned to aspirin alone without recurrence of thrombosis.

Topics: Adalimumab; Anti-Inflammatory Agents; Antiphospholipid Syndrome; Aspirin; Crohn Disease; Female; Hand; Humans; Ischemia; Middle Aged; Peripheral Vascular Diseases; Radial Artery; Warfarin

Oral anticoagulation prevents thromboembolism in atrial fibrillation. Factor Xa inhibitors, like edoxaban, are known to reduce inflammation and proliferation of smooth muscle cells, while vitamin K antagonism can cause vascular calcific damage. The influence of edoxaban compared to warfarin on vascular remodeling, atherosclerosis and arteriogenesis is unknown.. Apolipoprotein E knockout (ApoE. There was no difference in hind-limb perfusion restoration between the three groups after 14 days (Co 0.36 ± 0.05 vs. Warf 0.39 ± 0.09 (p = .39), Co vs. Edo 0.51 ± 0.06 (p = .089), Warf vs. Edo (p = .83)) after ligation. Immuno-histologically, there was no difference in smooth muscle cell count in both hindlimbs between the three groups or in the amount of perivascular macrophages in collateral-bearing hindlimb tissue. Edoxaban showed the lowest amount of plaque tissue in the aortic sinus tissue (Co 74 ± 11% vs. Edo 62 ± 12% (p = .024), Co vs. Warf 69 ± 14% (p = .30), Edo vs. Warf (p = .14)) as well as the least amount of fibrosis (Co 3.1 ± 0.9% vs. Edo 1.7 ± 0.6% (p = .027), Co vs. Warf 4.1 ± 0.7% (p = .081), Edo vs. Warf (p < .001)). No difference in mRNA content of inflammatory cytokines in muscle tissue or spleen was detected between the three groups.. These data suggest that treatment with edoxaban unlike warfarin prevents vascular maladaptive remodeling, which may be clinically important.

Topics: Animals; Anticoagulants; Atherosclerosis; Collateral Circulation; Disease Models, Animal; Factor Xa Inhibitors; Fibrosis; Hindlimb; Ischemia; Mice, Inbred C57BL; Mice, Knockout, ApoE; Muscle, Skeletal; Neovascularization, Physiologic; Plaque, Atherosclerotic; Pyridines; Thiazoles; Vascular Remodeling; Warfarin

In acute pancreatitis (AP), pancreatic damage leads to local vascular injury, manifesting as endothelial damage and activation, increased vascular permeability, leukocyte rolling, sticking and transmigration to pancreatic tissue as well as activation of coagulation. Previous studies have shown that pretreatment with heparin or acenocoumarol inhibits the development of AP. The aim of the present study was to check the impact of pretreatment with warfarin, an oral vitamin K antagonist, on the development of ischemia/reperfusion-induced AP in rats. AP was induced by pancreatic ischemia followed by reperfusion of the gland. Warfarin (90, 180 or 270 µg/kg/dose) or vehicle were administered intragastrically once a day for 7 days before induction of AP. The effect of warfarin on the severity of AP was assessed 6 h after pancreatic reperfusion. The assessment included histological, functional, and biochemical analyses. Pretreatment with warfarin given at a dose of 90 or 180 µg/kg/dose increased the international normalized ratio and reduced morphological signs of pancreatic damage such as pancreatic edema, vacuolization of acinar cells, necrosis and the number of hemorrhages. These effects were accompanied by an improvement of pancreatic blood flow and a decrease in serum level amylase, lipase, pro-inflammatory interleukin-1β and plasma level of D-dimer. In contrast, pretreatment with warfarin given at a dose of 270 µg/kg/dose led to an increase in severity of pancreatic damage and biochemical indicators of AP. In addition, this dose of warfarin resulted in deaths in some animals. Pretreatment with low doses of warfarin inhibits the development of AP induced by pancreatic ischemia followed by reperfusion.

Topics: Acute Disease; Animals; Anticoagulants; Coumarins; Ischemia; Male; Pancreas; Pancreatitis; Rats; Rats, Wistar; Reperfusion Injury; Warfarin

Venous gangrene complicating deep vein thrombosis in the context of anticoagulation use in patients with gynecologic malignancy is rarely reported. We report an unusual presentation of venous gangrene of the lower limbs associated with warfarin therapy in a 53-year-old woman from the Cook Islands with an occult ovarian cancer.. A 53-year-old woman of Cook Islands origin presented with exertional dyspnea, rapid atrial fibrillation, bilateral lower limb edema, and painful digital ischemia of her hallux. She was on warfarin therapy for atrial fibrillation and had a stable therapeutic international normalized ratio. Bilateral proximal lower limb deep vein thrombosis and digital gangrene subsequently developed in the setting of a supratherapeutic international normalized ratio and platelet count depletion. Her warfarin was reversed and heparin therapy was commenced with resulting correction of her thrombocytopenia.. We would like to attract the attention of the reader to the potential hazard of the use of warfarin in patients with malignancy. In our case, we also demonstrated a predictive value of supratherapeutic international normalized ratio and platelet count depletion that could herald massive thrombosis and gangrene in a patient who was previously stable on warfarin therapy. Early recognition and prompt reversal of warfarin in these circumstances is essential to correct the unbalanced prothrombotic process that leads to extensive thrombosis and gangrene. The outlook of such cases remains dismal and results in extensive morbidity and mortality.

Topics: Anticoagulants; Atrial Fibrillation; Female; Gangrene; Heparin; Humans; International Normalized Ratio; Ischemia; Middle Aged; Obesity, Morbid; Ovarian Neoplasms; Thrombocytopenia; Toes; Ultrasonography, Doppler; Venous Thrombosis; Warfarin

Venous limb gangrene (VLG) can occur in cancer patients, but the clinical picture and pathogenesis remain uncertain. We identified 10 patients with metastatic cancer (7 pathologically proven) who developed severe venous limb ischemia (phlegmasia/VLG) after initiating treatment of deep-vein thrombosis (DVT); in 8 patients, cancer was not known or suspected at presentation. The patients exhibited a novel, clinically distinct syndrome: warfarin-associated supratherapeutic international normalized ratio (INR; median, 6.5) at onset of limb ischemia, rising platelet count during heparin anticoagulation, and platelet fall after stopping heparin. Despite supratherapeutic INRs, patient plasma contained markedly elevated thrombin-antithrombin (TAT) complex levels (indicating uncontrolled thrombin generation) and protein C (PC) depletion; this profile resembles the greatly elevated TAT/PC activity ratios reported in patients with warfarin-associated VLG complicating heparin-induced thrombocytopenia. Analyses of vitamin K-dependent factors in 6 cancer patients with available serial plasma samples showed that variations in the INR corresponded most closely with changes in factor VII, with a highly collinear relationship between VII and PC. We conclude that venous limb ischemia/gangrene is explained in some cancer patients by profoundly disturbed procoagulant-anticoagulant balance, whereby warfarin fails to block cancer-associated hypercoagulability while nonetheless contributing to severe PC depletion, manifest as a characteristic supratherapeutic INR caused by parallel severe factor VII depletion.

Topics: Aged; Anticoagulants; Antithrombin III; Blood Coagulation Factors; Blood Platelets; Female; Follow-Up Studies; Gangrene; Heparin; Humans; International Normalized Ratio; Ischemia; Leg; Male; Middle Aged; Neoplasms; Peptide Hydrolases; Prognosis; Protein C Deficiency; Syndrome; Venous Thrombosis; Vitamin K; Warfarin

In this issue of Blood, Warkentin et al describe a novel clinical syndrome of warfarin-associated severe venous limb ischemia occurring in a series of 10 patients with malignancy after initiating treatment of deep venous thrombosis. Patients in this series also demonstrated a decline in platelet counts after stopping heparin, warfarin-associated supratherapeutic international normalized ratios (INRs), and evidence of persistent thrombin generation despite anticoagulation.

Topics: Anticoagulants; Female; Gangrene; Humans; Ischemia; Leg; Male; Neoplasms; Venous Thrombosis; Warfarin

Acute limb ischemia (ALI) in pediatric patients is rare but may lead to limb loss and life-long complications. This study reviewed the experience of a Canadian tertiary pediatric center with the medical and operative management of ALI.. The medical records of inpatients diagnosed with ALI of the upper or lower limb between 1999 and 2012 were reviewed. Patient demographics, arterial clot site and etiology, intervention, anticoagulation type and duration, and short-term and long-term complications were analyzed.. A total of 151 patients (45% female) presented with signs of limb ischemia, of whom 38% were aged <30 days, 46% were between 1 and 12 months, and 16% were between 1 and 18 years. Ninety-four percent of those injuries involved the lower limbs. Ninety-one percent were due to vessel catheterization, 5% were idiopathic, 1% were congenital, and 4% traumatic. Ninety-four percent were managed nonoperatively. Patients were treated with a combination of thrombolysis, unfractionated or low-molecular-weight heparin, aspirin or warfarin, or both (duration, 1 day-13 years). All patients were monitored after discharge at our institution or at their referring hospital (average, 3.4 ± 2.8 years). Fifteen percent had complications related to ALI or anticoagulation (most commonly limb length or thigh circumference discrepancy, or intracranial hemorrhage). Nineteen percent of patients died of unrelated causes (sepsis, multiorgan dysfunction, or cardiac failure).. In contrast with adults, ALI in children can generally be managed nonoperatively with anticoagulation, likely because of their greater ability to develop arterial collaterals. Long-term follow-up by a multidisciplinary team of pediatric and surgical specialists and allied health professionals is integral to achieving a successful outcome in children with ALI.

Topics: Acute Disease; Adolescent; Anticoagulants; Aspirin; Canada; Catheterization, Peripheral; Child; Child, Preschool; Female; Fibrinolytic Agents; Heparin, Low-Molecular-Weight; Hospitals, Pediatric; Humans; Infant; Intracranial Hemorrhages; Ischemia; Lower Extremity; Male; Organ Size; Retrospective Studies; Tertiary Care Centers; Upper Extremity; Warfarin

Purple toe syndrome is a recognised adverse effect of warfarin therapy. The literature has described resolution of the ischaemic symptoms on withdrawal of the warfarin and switching to a low molecular weight heparin alternative. We present a case of an 82-year-old man with bilateral blanching vivacious toes and a livedo-reticularis type rash developing 2 weeks after being loaded with warfarin for first detected atrial fibrillation. Vascular surgical review and haematology thrombotic screen did not yield any other pathology and a diagnosis of purple toe syndrome due to warfarin was carried out. The warfarin was stopped and oral anticoagulation started with an oral factor Xa inhibitor, apixaban with resolution of his symptoms. This is the first case report of one of the novel oral anticoagulants being used to treat purple toe syndrome.

Topics: Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Factor Xa Inhibitors; Humans; Ischemia; Male; Pyrazoles; Pyridones; Stroke; Toes; Warfarin

Dabigatran etexilate (DE) has recently been introduced for stroke prevention in atrial fibrillation, but management of acute ischaemic stroke during therapy with DE is a challenge. Thrombolysis is contraindicated because of a presumed increased risk of intracerebral haemorrhagic complications. We studied in different ischaemia models whether DE increases secondary haemorrhage after thrombolysis. C57BL/6 mice were anticoagulated with high-dose DE or warfarin. After 2 hour (h) or 3 h transient filament MCAO, rt-PA was injected. At 24 h after MCAO, secondary haemorrhage was quantified using a macroscopic haemorrhage score and haemoglobin spectrophotometry. Post-ischaemic blood-brain-barrier (BBB) damage was assessed using Evans blue. To increase the validity of findings, the duration of anticoagulation was prolonged in mice (5 x DE over 2 days), and the effect of DE after thrombolysis was also examined in thromboembolic MCAO in rats.Pretreatment with warfarin resulted in significantly more secondary haemorrhage (mean haemorrhage score 2.6 ± 0.2) compared to non-anticoagulated animals (1.7 ± 0.3) and DE (9 mg/kg, 1.6 ± 0.3) in 2 h ischaemia. Also after a 3 h period of ischaemia, haemorrhage was more severe in animals anticoagulated with warfarin compared to 9 mg/kg DE and non-anticoagulated control. Prolonged or enteral dabigatran pretreatment led to identical results. Also, thrombolysis after thromboembolic MCAO in rats did not induce more severe bleeding in DE-treated animals. Mice pretreated with warfarin had higher BBB permeability and increased activation of matrix-metalloproteinase 9. In conclusion, DE does not increase the risk of secondary haemorrhage after thrombolysis in various rodent models of ischaemia and reperfusion. The implications of this finding for stroke patients have to be determined in the clinical setting.

Topics: Animals; Anticoagulants; Antithrombins; Benzimidazoles; beta-Alanine; Blood-Brain Barrier; Cerebral Arteries; Cerebral Hemorrhage; Dabigatran; Disease Models, Animal; Humans; Ischemia; Mice; Mice, Inbred C57BL; Rats; Stroke; Thrombolytic Therapy; Warfarin

Cholesterol crystal embolism (CCE) is a serious complication associated with invasive vascular procedures. The prognosis of the renal involvement type of CCE is very poor, and there is currently no established treatment, other than supportive therapy. We herein report four cases of CCE with severe atherosclerosis wherein the renal function progressively deteriorated after cardiac catheterization. In three of the four patients, low-dose corticosteroids (0.3 mg/kg/day) improved the renal function, whereas the fourth patient died from CCE of the digestive system. This report reviews the literature on CCE and discusses possible therapeutic options.

Topics: Acute Kidney Injury; Aged; Aortography; Cardiac Catheterization; Comorbidity; Coronary Angiography; Coronary Disease; Crystallization; Embolism, Cholesterol; Fatal Outcome; Humans; Intestinal Perforation; Intestines; Ischemia; Leg; Livedo Reticularis; Male; Middle Aged; Peripheral Vascular Diseases; Prednisolone; Recurrence; Toes; Warfarin

A case of a 30-year-old woman with an end-stage renal disease and recently diagnosed with infective endocarditis, who presented with acute abdominal pain. An initial assessment of acute appendicitis was made. A CT scan of the abdomen showed a partially occluded superior mesenteric artery with radiographic evidence of ischaemia in an ileal loop. Intraoperatively, a 5-6 cm segment of the distal ileum was found to be non-viable. The segment was resected with the creation of a double-barrel ileostomy. This case report draws attention to the question of a need for anticoagulation for a septic embolus in the superior mesenteric artery. We could not find evidence on the use of postoperative anticoagulation in this scenario. In this case, the patient was started on oral anticoagulation.

Topics: Adult; Anticoagulants; Endocarditis, Bacterial; Female; Humans; Ischemia; Mesentery; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography; Warfarin

Mesenteric venous thrombosis (MVT) is a rare but life threatening form of bowel ischemia. It is implicated in 6%-9% of all cases of acute mesenteric ischemia. The proportion of patients with primary (or idiopathic) MVT varies from 0% to 49%, with a decrease in frequency secondary to more recent availability of newer investigations for hypercoagulability. The presence of factor V Leiden (FVL) and prothrombin G20210A mutations (PGM) have been well documented in these cases. However, there have been scarce case reports describing MVT in heterozygotes of both these mutations occurring simultaneously and its implications on long term management. Our case describes acute MVT in a previously asymptomatic young patient with no prior history of venous thromboembolism. The patient was found to be heterozygous for FVL and PGM and treated with lifelong anticoagulation with warfarin (goal international normalized ratio: 2-3) and avoidance of hormonal contraceptives.

Topics: Activated Protein C Resistance; Anticoagulants; Blood Coagulation; DNA Mutational Analysis; Factor V; Female; Genetic Predisposition to Disease; Heterozygote; Humans; International Normalized Ratio; Ischemia; Mesenteric Ischemia; Mesenteric Vascular Occlusion; Mesenteric Veins; Mutation; Phenotype; Phlebography; Prothrombin; Tomography, X-Ray Computed; Vascular Diseases; Venous Thrombosis; Warfarin; Young Adult

This article presents a case of a 17-year-old girl with primary antiphospholipid syndrome developing subacute signs of hand and leg ischaemia caused by radiologically verified radial and popliteal artery occlusion. She is successfully treated with a thrombolytic agent (alteplase) and recovers completely. Her laboratory results came positive for all three subtypes of antiphospholipid antibodies. This kind of antiphospholipid syndrome presentation is a very rare entity in itself. Shortly afterwards her mother is diagnosed with primary antiphospholipid syndrome as well. A familial form of antiphospholipid syndrome is suspected. Combination of a familial antiphospholipid syndrome presenting as bivessel arterial thrombosis is a unique case, to the best of our knowledge, never described in the literature before.

Topics: Administration, Oral; Adolescent; Angiography, Digital Subtraction; Antibodies, Antiphospholipid; Anticoagulants; Antiphospholipid Syndrome; Arterial Occlusive Diseases; Biomarkers; Constriction, Pathologic; Female; Fibrinolytic Agents; Genetic Predisposition to Disease; Heredity; Humans; Ischemia; Pedigree; Popliteal Artery; Radial Artery; Thrombolytic Therapy; Tissue Plasminogen Activator; Treatment Outcome; Warfarin

A 30-year-old man with a history of bilateral deep vein thromboses and recurrent penile ischemic episodes presented for distal penile amputation and skin graft. Despite suspicion, serologies indicated no hypercoagulable disorder. After surgery, the patient was bridged from enoxaparin to warfarin. Nine days after initiation of warfarin therapy, he developed necrotic arm ulcers, which were subsequently proved to be secondary to warfarin-induced skin necrosis.

Topics: Adult; Anticoagulants; Humans; Ischemia; Male; Necrosis; Penis; Skin; Warfarin

Topics: Aged; Angiography, Digital Subtraction; Angioplasty; Brachial Artery; Embolectomy; Embolism; Forearm; Hand; Heparin; Heparin, Low-Molecular-Weight; Humans; Ischemia; Male; Postoperative Care; Postoperative Complications; Radial Artery; Suction; Ulnar Artery; Ultrasonography, Doppler, Color; Urinary Bladder Neoplasms; Warfarin

Topics: Aged; Antibodies, Anticardiolipin; Anticoagulants; Arginine; Catheterization; Contraindications; Drug Therapy, Combination; Femoral Vein; Heparin; Humans; Iliac Vein; Infusions, Intravenous; Ischemia; Kidney; Kidney Transplantation; Male; Pipecolic Acids; Popliteal Vein; Postoperative Complications; Protein S Deficiency; Purpura, Thrombocytopenic, Idiopathic; Renal Veins; Sulfonamides; Thrombolytic Therapy; Thrombophilia; Tissue Plasminogen Activator; Vena Cava Filters; Venous Thrombosis; Warfarin

Topics: Aged; Anti-Infective Agents; Anticoagulants; Drug Interactions; Gastrointestinal Hemorrhage; Humans; Ischemia; Leg; Male; Nalidixic Acid; Postoperative Hemorrhage; Thromboembolism; Urethritis; Warfarin

Topics: Adolescent; Humans; Ischemia; Lower Extremity; Male; Nephrotic Syndrome; Thrombosis; Warfarin

Topics: Anticoagulants; Aorta, Thoracic; Arm; Clopidogrel; Coronary Artery Disease; Echocardiography, Transesophageal; Humans; Ischemia; Male; Middle Aged; Platelet Aggregation Inhibitors; Thromboembolism; Ticlopidine; Warfarin

Controversy regarding the efficacy of duplex ultrasound surveillance after infrainguinal vein bypass led to an analysis of patient and bypass graft characteristics predictive for development of graft stenosis and a decision of secondary intervention.. Retrospective analysis of a contemporary, consecutive series of 353 clinically successful infrainguinal vein bypasses performed in 329 patients for critical (n = 284; 80%) or noncritical (n = 69; 20%) limb ischemia enrolled in a surveillance program to identify and repair duplex-detected graft stenosis. Variables correlated with graft stenosis and bypass repair included: procedure indication, conduit type (saphenous vs nonsaphenous vein; reversed vs nonreversed orientation), prior bypass graft failure, postoperative ankle-brachial index (ABI) < 0.85, and interpretation of the first duplex surveillance study as "normal" or "abnormal" based on peak systolic velocity (PSV) and velocity ratio (Vr) criteria.. Overall, 126 (36%) of the 353 infrainguinal bypasses had 174 secondary interventions (endovascular, 100; surgery, 74) based on duplex surveillance; resulting in 3-year Kaplan-Meier primary (46%), assisted-primary (80%), and secondary (81%) patency rates. Characteristics predictive of duplex-detected stenosis leading to intervention (PSV: 443 +/- 94 cm/s; Vr: 8.6 +/- 9) were: "abnormal" initial duplex testing indicating moderate (PSV: 180-300 cm/s, Vr: 2-3.5) stenosis (P < .0001), non-single segment saphenous vein conduit (P < .01), warfarin drug therapy (P < .01), and redo bypass grafting (P < .001). Procedure indication, postoperative ABI level, statin drug therapy, and vein conduit orientation were not predictive of graft revision. The natural history of 141 (40%) bypasses with an abnormal first duplex scan differed from "normal" grafts by more frequent (51% vs 24%, P < .001) and earlier (7 months vs 11 months) graft revision for severe stenosis and a lower 3-year assisted primary patency (68% vs 87%; P < .001). In 52 (15%) limbs, the bypass graft failed and 20 (6%) limbs required amputation.. The efficacy of duplex surveillance after infrainguinal vein bypass may be enhanced by modifying testing protocols, eg, rigorous surveillance for "higher risk" bypasses, based on the initial duplex scan results and other characteristics (warfarin therapy, non- single segment saphenous vein conduit, redo bypass) predictive for stenosis development.

Topics: Anticoagulants; Extremities; Female; Graft Occlusion, Vascular; Humans; Ischemia; Male; Postoperative Care; Reoperation; Retrospective Studies; Risk Factors; Saphenous Vein; Time Factors; Treatment Failure; Ultrasonography, Doppler, Duplex; Vascular Patency; Vascular Surgical Procedures; Warfarin

Warfarin reduces the risk of stroke in patients with atrial fibrillation. Despite strong guideline recommendations, studies continue to demonstrate the under-use of warfarin in clinical practice.. To determine the prevalence and predictors of warfarin use in patients presenting with atrial fibrillation and acute ischemic stroke who do not have a documented contraindication to anticoagulants.. We conducted a retrospective chart review of all patients admitted to the Hamilton General Hospital with a primary diagnosis of ischemic stroke and a coded diagnosis of atrial fibrillation between 1999 and 2004. Using a standardized data abstraction form, the following variables were recorded: baseline demographics, past medical history including risk factors for stroke and major bleeding and known predictors of warfarin under-use. In cases where warfarin was not prescribed, charts were also reviewed for documented contraindications to warfarin use. The following were considered valid contraindications to warfarin: patient refusal, non-compliance with INR monitoring, bleeding diathesis, history of major bleeding or significant alcohol consumption.. In total, 196 patients with ischemic stroke and atrial fibrillation were identified. Of these patients, 106 were considered to be appropriate candidates for anticoagulation after excluding patients with no known diagnosis of atrial fibrillation prior to admission (N=59), a valid contraindication to warfarin use (N=18), a CHADS2 score <1 (N=6) or a competing diagnosis for warfarin use (N=7). Of the patients deemed to be suitable candidates for warfarin, 57 (54%) were receiving warfarin therapy on admission. On multivariable analyses, increasing age (OR 0.7; 95% CI 0.5-0.9) was associated with a reduced odds of warfarin use while a history of stroke or TIA (OR 2.6; 95% CI 1.1-6.5) and a history of congestive heart failure (OR 3.2; 95% CI 1.1-9.0) were associated with an increased odds of warfarin use in patients without a contraindication to warfarin. While 75% of patients <75 years old were anticoagulated, only 33% of those >85 years were prescribed warfarin on admission to hospital.. early half of all patients presenting with atrial fibrillation and acute ischemic stroke who were suitable candidates for anticoagulation were not prescribed warfarin. In patients not prescribed warfarin, very few had a documented contraindication. Advanced age appears to be the strongest predictor of warfarin non-use.

Topics: Acute Disease; Administration, Oral; Aged; Anticoagulants; Atrial Fibrillation; Female; Humans; Ischemia; Male; Middle Aged; Multivariate Analysis; Risk Factors; Stroke; Treatment Outcome; Warfarin

We sought to describe modes of failure and associated limb loss after infrainguinal polytetrafluoroethylene bypass grafting in patients lacking a saphenous venous conduit and to define specific clinical or hemodynamic factors prognostic for bypass failure.. We identified 121 patients (mean age, 67 years; 90 men and 31 women) with determinable outcomes (minimum follow-up, 2 months; mean, 17 months) after 130 prosthetic infrainguinal bypasses between 1997 and 2005. Ischemic presentation was rest pain in 52%, tissue loss in 34%, and disabling claudication and/or popliteal aneurysm in 14%, with 24% of patients requiring a redo bypass. Distal targets were the above-knee (n = 44), distal popliteal (n = 27), or tibial/pedal (n = 59) arteries. Sixty-six (77%) of the below-knee (BK) target (distal popliteal or tibial) bypasses had distal anastomotic adjuncts (vein cuff or patch). Duplex graft surveillance was performed at 1, 4, and 7 months after surgery and twice yearly thereafter, with recording of midgraft velocities and imaging encompassing inflow and outflow vessels. Arteriography and open/endovascular intervention was performed for stenoses identified by duplex scanning (peak systolic velocity >300 cm/s; velocity ratio >3.5). An attempt was made to salvage occluded grafts by using catheter-directed thrombolysis or open techniques. Eighty-six patients (74% of BK bypasses) were placed on chronic warfarin therapy with a target international normalized ratio range between 2 and 3. Prognostic factors were identified by using univariate statistics and multivariate logistic regression analysis.. Three-year primary, assisted, and secondary patency rates were 39%, 43%, and 59%, respectively, for all bypasses, with no difference noted between above-knee and BK grafts (P = .5). At 3 years, freedom from limb loss was 75%, and patient survival was only 70%, with no adverse effect on survival imparted by amputation. Sixty-nine total adverse events occurred as a result of thrombotic occlusion (n = 51), duplex scan-detected stenosis (n = 13), or graft infection (n = 5). Forty-nine percent of all initial graft occlusions eventually led to amputation. Twenty-three grafts (27% of 86 patients) in patients maintained on chronic warfarin were subtherapeutic at the time of occlusion. Use of a distal anastomotic adjunct with BK bypasses reduced graft thrombosis (35% with vs 60% without) but did not impart a significant patency advantage (P = .07). Multivariate analysis revealed low graft flow (midgraft velocity < or =45 cm/s; odds ratio [OR], 6.1; 95% confidence interval [CI], 1.9-19.2), use of warfarin (OR, 8.4; 95% CI, 2.1-34.5), and therapeutic warfarin (OR, 24.6; 95% CI, 5.7-106) to be independently predictive for bypass patency. Graft patency was maintained in 89% of grafts remaining therapeutic on warfarin compared with only 55% of subtherapeutic or nonanticoagulated grafts (P < .001). Low-flow grafts (n = 61) occluded more frequently than higher-flow grafts (46% vs 13%; P < .001). Therapeutic warfarin augmented the patency of low-flow (P < .001) but not high-flow (P = .15) grafts.. Low graft flow was a more common mode of prosthetic bypass failure than development of duplex scan-detected stenotic lesions during follow-up. Early duplex scanning may be more important for characterizing midgraft velocity and related thrombotic potential and selecting patients for chronic anticoagulation. Maintenance of therapeutic warfarin is paramount in optimizing prosthetic bypass patency and limb preservation.

Topics: Aged; Aged, 80 and over; Amputation, Surgical; Anticoagulants; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Female; Follow-Up Studies; Graft Occlusion, Vascular; Humans; Ischemia; Limb Salvage; Logistic Models; Lower Extremity; Male; Middle Aged; Odds Ratio; Patient Selection; Polytetrafluoroethylene; Prosthesis Design; Prosthesis Failure; Regional Blood Flow; Retrospective Studies; Risk Assessment; Risk Factors; Thrombosis; Time Factors; Treatment Failure; Ultrasonography, Doppler, Duplex; Vascular Patency; Warfarin

Topics: Adult; Anticoagulants; Carotid Artery, Internal; Carotid Stenosis; Coronary Angiography; Drug Therapy, Combination; Eye; Female; Fluorescein Angiography; Heparin, Low-Molecular-Weight; Humans; Ischemia; Retinal Artery Occlusion; Scleroderma, Diffuse; Syndrome; Ultrasonography, Doppler; Warfarin

Emerging findings have demonstrated the critical role of blood clotting factors in the formation and stabilization of embryonic blood vessels. Whether a similar role is true during post-natal angiogenesis remains to be determined. Here we sought to determine whether the suppression of thrombin generation with anticoagulant drugs at doses routinely used for therapeutic purposes would affect the angiogenesis pattern following hindlimb ischemia in rats. Animals were treated with r-hirudin or enoxaparin within six hours post induction of hindlimb ischemia, whereas two other groups received oral anticoagulation warfarin beginning at day 3 post-ischemia or saline (as control). The revascularization anatomical and functional responses were evaluated 30 days following tissue ischemia. Chronic administration of the drugs resulted in stable anticoagulation in all animals throughout the experiment. Animals that received drugs with fast anticoagulation effects (i.e. r-hirudin and enoxaparin) presented a significant decrease in capillary density and capillary-to-myocyte ratio compared to control animals. These effects were not associated with changes in relative perfusion of the hindlimb at steady state. These anti-angiogenic effects occur in a time-dependent manner, since delayed inhibition of coagulation (>72 hours) presents no adverse effect on the angiogenic response. We conclude that the use of anticoagulant drugs immediately after tissue ischemia induction hampers in vivo angiogenic response in a rodent hindlimb ischemia model.

Topics: Animals; Anticoagulants; Blood Coagulation Factors; Disease Models, Animal; Enoxaparin; Hindlimb; Hirudins; Ischemia; Kinetics; Neovascularization, Physiologic; Rats; Rats, Inbred Lew; Time Factors; Warfarin

Microvascular circulation disturbances including erythromelalgia, its microvascular ischemic complications, and migraine-like atypical or typical transient ischemic cerebral, ocular, and coronary ischemic attacks are specific clinical manifestations in patients with essential thrombocythemia (ET), and polycythemia vera (PV) associated with thrombocythemia. Thrombocythemia (ET and PV) patients with microvascular disturbances have shortened platelet survival, increased beta-thromboglobulin (beta-tg), platelet factor 4 (PF4), and thrombomoduline (TM) levels, and increased urinary thromboxane B2 (TxB2) excretion indicating platelet-mediated processes in vivo. Inhibition of platelet cyclooxygenase (COX 1) by aspirin is followed by relief of microvascular disturbances, correction of shortened platelet survival, and return of plasma levels of beta-tg, PF4, TM levels and TxB2 excretion to normal. The transient ischemic attacks and thrombotic complications in thrombocythemia are very likely caused by hypersensitive platelets produced by spontaneously proliferating enlarged megakaryocytes in the bone marrow of ET and PV patients. In contrast to normal platelets in healthy individuals the circulating hypersensitive thrombocythemic platelets spontaneously activate and secrete their products, thus forming aggregates that transiently plug the microcirculation, or result in occlusive platelet thrombi in arterioles or small arteries. Clear evidence is presented that the microvascular transient ischemic and occlusive thrombotic complications in thrombocythemia patients are relieved by treatment with aspirin and by reduction of platelet counts to normal (<400 x 109/l), but not by coumadin. In patients with thrombocythemia associated with PV, increased hematocrit and whole blood viscosity aggravate the platelet-mediated microvascular ischemic and thrombotic syndrome of thrombocythemia to major arterial and venous thrombotic complications. Correction of hematocrit and blood viscosity by phlebotomy significantly reduces the major arterial and venous thrombotic complications, but fails to prevent the platelet-mediated microvascular circulation disturbances in PV patients because thrombocythemia persists. Complete relief and prevention of microvascular and major thrombosis in PV patients are obtained by treatment with low-dose aspirin on top of phlebotomy or by treatment with the platelet lowering agents, anagrelide, interferon or hydroxyurea.

Topics: Aged; Anticoagulants; Aspirin; Drug Resistance; Erythromelalgia; Female; Humans; Ischemia; Male; Microcirculation; Middle Aged; Phlebotomy; Platelet Aggregation Inhibitors; Polycythemia Vera; Thrombocythemia, Essential; Thrombophilia; Thrombosis; Warfarin

Topics: Abciximab; Antibodies, Monoclonal; Aorta, Abdominal; Aortic Diseases; Calcinosis; Combined Modality Therapy; Drug Therapy, Combination; Femoral Artery; Heparin; Humans; Immunoglobulin Fab Fragments; Ischemia; Magnetic Resonance Imaging; Male; Middle Aged; Platelet Aggregation Inhibitors; Sensation Disorders; Spinal Cord; Thrombosis; Urinary Incontinence; Warfarin

Microvascular thrombosis is a prominent feature in cardiac delayed xenograft rejection (DXR). We investigated the impact of warfarin or low-molecular-weight heparin (LMWH) anti-coagulation on xenograft function using a heterotopic pig-to-primate model. Donor hearts were from CD46 transgenic pigs and baboon immunosuppression included tacrolimus, sirolimus, anti-CD20 and TPC, an alpha-galactosyl-polyethylene glycol conjugate. Three groups of animals were studied. Group 1 (n = 9) was treated with warfarin, Group 2 (n = 13) with LMWH and Group 3, received no anti-coagulant drugs. The median duration of xenograft function was 20 days (range 3-62 days), 18 days (range 5-109 days) and 15 days (range 4-53 days) in Groups 1 to 3 respectively. Anti-coagulation achieved the targeted international normalized prothrombin ratio (INR) and anti-factor Xa levels consistent with effective in vivo therapy yet, no significant impact on median xenograft function was observed. At rejection, a similar histology of thrombosis and ischemia was apparent in each group and the levels of fibrin deposition and platelet thrombi in rejected tissue was the same. Anti-coagulation with warfarin or LMWH did not have a significant impact on the onset of DXR and microvascular thrombosis. However, a role for specific anti-coagulant strategies to achieve long-term xenograft function cannot be excluded.

Topics: Animals; Animals, Genetically Modified; Anticoagulants; Antigens, CD; Factor Xa; Heart Transplantation; Heparin, Low-Molecular-Weight; Immunoglobulin G; Immunoglobulin M; Immunosuppressive Agents; International Normalized Ratio; Ischemia; Membrane Cofactor Protein; Membrane Glycoproteins; Microcirculation; Myocardium; Papio; Primates; Prothrombin; Sirolimus; Swine; Tacrolimus; Thrombosis; Time Factors; Transplantation, Heterologous; Treatment Outcome; Vitamin K; Warfarin

Secondary preventive measures play an important role in the reduction of stroke, the third largest cause of death in Scotland. We investigated whether sex, age, or deprivation differences existed in the secondary prevention of stroke in primary care.. A retrospective cross-sectional study using a computerized database with 61 practices (377,439 patients) to identify group differences in secondary preventive therapy between March 2003 and April 2004 for 10,076 patients with a diagnosis of any stroke.. Women with any stroke were more likely than men to be prescribed a thiazide (odds ratios [OR], 1.60; 95% confidence interval [CI], 1.46 to 1.75) but less likely to be prescribed an angiotensin-converting enzyme inhibitor (OR, 0.73; 95% CI, 0.67 to 0.81). Women with ischemic stroke were less likely to receive either an antiplatelet or warfarin (OR, 0.84; 95% CI, 0.75 to 0.94) or statin therapy (OR, 0.82; 95% CI, 0.74 to 0.90) than men. Women with atrial fibrillation received less warfarin (OR, 0.62; 95% CI, 0.48 to 0.81) but more antiplatelet therapy than men (OR, 1.30; 95% CI, 1.00 to 1.68). The oldest patients (older than 75 years) with ischemic stroke received more antiplatelet therapy than the youngest patients (younger than 65 years) (OR, 1.83; 95% CI, 1.64 to 2.06). No significant differences in secondary preventative treatment across deprivation groups were found.. Important sex and age differences exist in the care of patients with stroke and suggest that women and the elderly need to be targeted for secondary prevention therapy.

Topics: Age Factors; Aged; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Antihypertensive Agents; Female; Humans; Ischemia; Logistic Models; Male; Middle Aged; Odds Ratio; Platelet Aggregation Inhibitors; Primary Health Care; Retrospective Studies; Scotland; Sex Factors; Stroke; Warfarin

In patients with atrial fibrillation (AF), oral anticoagulant therapy (OAT) is effective in reducing stroke and embolism. However, despite OAT, ischemic events do occur in some patients. Studies specifically addressing the identification of risk factors for ischemic events during well-conducted OAT are not available. In this study, we prospectively investigated the role of classic risk factors and homocysteine levels in the occurrence of ischemic complications in 364 AF patients on OAT.. The quality of anticoagulation levels and the occurrence of bleeding and thrombotic events were recorded.. During follow-up (859 patient years) 21 patients had ischemic complications (rate 2.4 x 100 patient-years). Homocysteine plasma levels were higher in these patients than in patients without ischemic complications during OAT (P<0.01), whereas no difference was observed in relation to the quality of OAT. The presence of a history of previous ischemic events, hypertension, and homocysteine plasma levels over the 90th percentile were all associated with an increased risk of ischemic events during OAT (odds ratio [OR]=7, 4.5, and 4.7, respectively). The coexistence of these risk factors markedly increased the risk (OR=13.1; 95% CI, 3.7 to 45.7; P=0.001).. In conclusion, our results indicate that AF patients with multiple risk factors may not be sufficiently protected by OAT, even when this is well conducted.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Echocardiography; Female; Follow-Up Studies; Homocysteine; Humans; Ischemia; Male; Middle Aged; Models, Statistical; Multivariate Analysis; Odds Ratio; Prospective Studies; Regression Analysis; Research Design; Risk; Risk Factors; Stroke; Time Factors; Treatment Failure; Treatment Outcome; Warfarin

With the changes in management of atrial fibrillation (AF) over time, it is possible that the time trends of post-AF stroke incidence and mortality have changed. We sought to determine whether the incidence and survival of ischemic stroke after AF diagnosis have improved.. We identified the Olmsted County, Minn, residents who developed first AF from 1980 to 2000 and followed them in medical records to 2004. The outcomes were first ischemic stroke and death.. Of the 4117 subjects diagnosed with first AF and without previous stroke, 446 (11%) sustained a first ischemic stroke during a mean follow-up time of 5.5+/-5.0 years. The age- and sex-adjusted incidence of stroke decreased, on average, by 3.4% per year (P=0.0001), concurrent with an increase in warfarin and aspirin use (both P<0.0001) and reduction of systolic blood pressure (P<0.001). The age-adjusted ischemic stroke incidence was higher in women (P=0.039), but not after adjusting for systolic blood pressure (P=0.41). Compared with the general Minnesota white population, the relative mortality hazard ratio was 1.88 for men and 1.84 for women without stroke and 3.03 for men and 3.80 for women (P<0.05) with stroke. The relative mortality hazard did not vary by age or calendar year of AF diagnosis.. Post-AF ischemic stroke incidence decreased significantly from 1980 to 2000, during which time a substantial increase in the use of antithrombotic therapy and reduction of systolic blood pressure was evident. The relative mortality risk of stroke, however, had not improved over time.

Topics: Adolescent; Adult; Age Factors; Aged; Aged, 80 and over; Aspirin; Atrial Fibrillation; Blood Pressure; Female; Fibrinolytic Agents; Humans; Incidence; Ischemia; Male; Medical Records; Middle Aged; Multivariate Analysis; Proportional Hazards Models; Regression Analysis; Risk; Sex Factors; Stroke; Time Factors; Treatment Outcome; Warfarin

Necrosis of the digits is a rare complication of warfarin therapy of obscure pathogenesis. We report a 61-year-old woman with a 12-month history of Raynaud's phenomenon who developed multiple digital necrosis following aortic valve replacement with mechanical prosthesis for aortic insufficiency caused by nonbacterial thrombotic endocarditis. Exacerbation of Raynaud's phenomenon occurred during the postoperative period, with daily episodes of ischemia of the fingers and toes that improved with local warming. However, coincident with the occurrence of immune heparin-induced thrombocytopenia, and while undergoing routine warfarin anticoagulation because of the mechanical valve prosthesis, the patient abruptly developed progression of digital ischemia to multiple digital necrosis on postoperative day 8, at the time the international normalized ratio reached its peak value of 4.3. All limb pulses were readily palpable, and vascular imaging studies showed thrombosis only in the superficial femoral and popliteal veins of the right leg. Coagulation studies showed greatly elevated levels of thrombin-antithrombin complexes and prothrombin fragment F1.2 levels, consistent with uncontrolled thrombin generation. After vitamin K administration, no abnormalities of the protein C anticoagulant pathway were identified, consistent with previous studies of other patients with warfarin-induced necrosis complicating heparin-induced thrombocytopenia. Subsequently, the patient was shown to have metastatic breast adenocarcinoma, which explained the patient's initial presentation with nonbacterial thrombotic endocarditis. This patient case suggests that multiple digital gangrene can result from the interaction of various localizing and systemic factors, including compromised microvascular blood flow (Raynaud's phenomenon), increased thrombin generation (heparin-induced thrombocytopenia, adenocarcinoma), and warfarin-induced failure of the protein C natural anticoagulant pathway.

Topics: Adenocarcinoma; Anticoagulants; Aortic Valve; Endocarditis; Female; Fingers; Heart Valve Prosthesis Implantation; Heparin; Humans; Ischemia; Middle Aged; Necrosis; Postoperative Period; Raynaud Disease; Thrombocytopenia; Thrombosis; Toes; Warfarin

The National Audit of Thrombolysis for Acute Leg Ischemia (NATALI) database is a consecutive series of patients who underwent intra-arterial thrombolysis to treat acute leg ischemia in one of 11 centers in the United Kingdom. The purpose of the study was to analyze the factors associated with outcome after 30 days.. The data were collected over 10 years on standard pro formas, and registration was completed at the end of 1999. Since then, data from each unit have been verified and missing data included when available. Univariate and multivariate analyses were performed, with the outcomes of amputation-free survival (AFS), amputation with survival, and death.. A total of 1133 thrombolytic events were included. Outcome results at 30 days for the entire group were AFS, 852 (75.2%); amputation, 141 (12.4%); and death, 140 (12.4%). Results for the entire group improved from the first half of the database, when AFS ranged from 65% to 75%, to almost 80% for the last few years of the study, although this was not statistically significant. Preintervention factors associated with lower AFS at multivariate analysis included diabetes (P =.002), increasing age (P <.001), short-duration ischemia (P =.027), Fontaine grade (P =.001), and ischemia with neurosensory deficit (P =.004). AFS was improved in patients receiving warfarin sodium at the time of the arterial occlusion (P =.04). Mortality was higher in women (P =.006) and in older patients (P <.001), and in patients with native vessel occlusion (P <.001), emboli (P =.02), or a history of ischemic heart disease (P <.001). Amputation risk was greatest in younger men (P <.001) and in patients with more severe ischemia (P =.02), graft occlusion (P <.001), or native vessel thrombotic occlusion (P =.02).. Experienced surgeons and radiologists can achieve an AFS of about 80% in selected patients with acute leg ischemia. Information from the NATALI database can be used in selection of an appropriate intervention in the individual patient.

Topics: Acute Disease; Aged; Amputation, Surgical; Anticoagulants; Databases, Factual; Female; Fibrinolytic Agents; Humans; Injections, Intra-Arterial; Ischemia; Leg; Male; Middle Aged; Multivariate Analysis; Prospective Studies; Streptokinase; Thrombolytic Therapy; Time Factors; Treatment Outcome; United Kingdom; Urokinase-Type Plasminogen Activator; Warfarin

Topics: Abdominal Abscess; Anticoagulants; Aortic Diseases; Arterial Occlusive Diseases; Arteriosclerosis; Calcinosis; Conversion Disorder; Diagnostic Errors; Female; Humans; Hypesthesia; Ischemia; Leg; Middle Aged; Muscle Denervation; Paraplegia; Peripheral Nerves; Thrombosis; Tibial Arteries; Tomography, X-Ray Computed; Warfarin

Portal vein thrombosis (PVT) is a complication of hepatic disease and a potentially lethal complication of splenectomy. The reported incidence of this complication is low (approximately 1%). However, its true incidence may have been underestimated due to difficulty in making the diagnosis. Herein we report the case of a 19 year-old woman who presented with a 2-year history of idiopathic thrombocytopenic purpura (ITP). Because she had become refractory to medical therapy, she underwent laparoscopic splenectomy. She was discharged on postoperative day 2 after an uncomplicated procedure. She did well, complaining only of mild backache, until postoperative day 21, when she presented with nausea, vomiting, and leukocytosis. CT showed PVT and superior mesenteric vein thrombosis. Despite heparin and fluid administration, her condition worsened. At laparotomy, she had diffuse small bowel edema and congestion. At a second-look procedure 24 h later, nearly all her jejunum and ileum were necrotic. After three procedures, she was left with 45 cm of proximal and 10 cm of distal small bowel. Bowel continuity was restored 8 weeks later. She continued on warfarin anticoagulation therapy for 1 year. Postsplenectomy PVT is most often seen following splenectomy for myeloproliferative disorders and almost never after trauma. The large splenic vein stump and the hypercoagulable state in patients with splenomegaly are thought to be contributory. The presentation of PVT is vague, without defining signs or symptoms. Color-flow Doppler and contrast-enhanced CT scans are the best methods for the nonoperative diagnosis of PVT. Aggressive thrombolysis offers the best hope for clot lysis and maintenance of bowel viability. Even vague symptoms must be considered seriously following splenectomy.

Topics: Adult; Anastomosis, Surgical; Anticoagulants; Back Pain; Combined Modality Therapy; Crystalloid Solutions; Diagnostic Errors; Female; Fluid Therapy; Heparin; Humans; Ileum; Immunosuppressive Agents; Ischemia; Isotonic Solutions; Jejunum; Laparoscopy; Mesenteric Veins; Muscular Diseases; Necrosis; Parenteral Nutrition; Plasma Substitutes; Plasmapheresis; Platelet Transfusion; Portal Vein; Postoperative Complications; Purpura, Thrombocytopenic, Idiopathic; Splenectomy; Splenomegaly; Venous Thrombosis; Warfarin

Topics: Adult; Bone and Bones; Bone Marrow; Fibrosis; Foot; Heparin; Humans; Intracranial Thrombosis; Ischemia; Male; Megakaryocytes; Peripheral Vascular Diseases; Reticulin; Tomography, X-Ray Computed; Warfarin

Arthroscopic posterior cruciate ligament reconstruction may carry certain risks of complications, including injury to the neurovascular structures in the popliteal region. Acute occlusion of the popliteal artery, a limb-threatening complication, was reported after total knee arthroplasty. We report a case of acute popliteal artery occlusion after arthroscopic posterior cruciate ligament reconstruction. The possible causes included underlying artherosclerosis, the use of pneumatic tourniquet, surgical manipulation, and arterial spasm. Early diagnosis and prompt surgical treatment are the keys to success in the treatment of this limb-threatening complication. Spontaneous resolution of the thrombus such as is reported in this case is exceptional.

Topics: Anticoagulants; Arterial Occlusive Diseases; Arthroscopy; Heparin; Humans; Ischemia; Joint Instability; Leg; Male; Middle Aged; Popliteal Artery; Posterior Cruciate Ligament; Postoperative Complications; Remission, Spontaneous; Thrombosis; Tourniquets; Warfarin

Recurrent thromboses, cerebral disease, miscarriages, and antiphospholipid antibodies are characteristic of the antiphospholipid syndrome. A 31-year-old man presented with limb ischemic and isolated right ventricular failure. Antiphospholipid syndrome was suspected and limb salvage was accomplished by anticoagulation and tibial- to-plantar artery bypass surgery. However, recurrent ischemic episodes were successfully treated with thrombolytic therapy and anticoagulants. The surgeon should be aware that patients with antiphospholipid antibodies and lupus anticoagulant antibodies have a high propensity for recurrent arterial thromboses and should use multiple therapeutic approaches to effect successful long-term limb salvage.

Topics: Adult; Anticoagulants; Antiphospholipid Syndrome; Combined Modality Therapy; Humans; Ischemia; Leg; Limb Salvage; Male; Recurrence; Thrombectomy; Thrombolytic Therapy; Thrombosis; Warfarin

Topics: Acute Disease; Adult; Aged; Amputation, Surgical; Anticoagulants; Aortic Diseases; Arterial Occlusive Diseases; Aspirin; Clopidogrel; Diagnosis, Differential; Echocardiography, Transesophageal; Female; Follow-Up Studies; Humans; Ischemia; Leg; Male; Middle Aged; Spain; Thrombectomy; Thrombosis; Ticlopidine; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

After thromboembolectomy, patients with acute limb ischemia often receive anticoagulant therapy to prevent recurrent events. Patients with atrial fibrillation or cardiac thrombus have a higher risk of recurrent emboli than those without these risk factors. This study examines the importance of long-term anticoagulation in these 2 groups.. A review of patients presenting with acute limb ischemia over a 5-year period (1994-1999).. A university-affiliated medical centre.. Fifty patients divided into 2 groups: 19 (38%) patients with atrial fibrillation (group 1) and 31 (62%) patients with no atrial fibrillation or cardiac thrombus (group 2) as confirmed by transthoracic echocardiography.. All patients underwent surgical thromboembolectomy and received postoperative anticoagulant therapy.. Mortality, limb loss, further thromboembolic events and bleeding complications as determined by telephone survey.. There was a significant difference in 5-year survival (group 1, 84%; group 2, 64%) and early limb loss (group 1, 0%; group 2, 13%). Further thromboembolic events and bleeding complications were rare but were more common in group 1. In group 2 there were no instances of recurrent thromboemboli and no bleeding complications although only 39% of patients in this group were taking angicoagulants at the end of the study period.. Patients with extremity thromboemboli without atrial fibrillation or cardiac thrombus may not be at the same risk for recurrent events as those with these risk factors, and long-term anticoagulant therapy may not be as necessary in this group.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Extremities; Female; Heart Diseases; Humans; Ischemia; Male; Middle Aged; Recurrence; Retrospective Studies; Risk Factors; Thrombectomy; Thromboembolism; Thrombosis; Time Factors; Treatment Outcome; Warfarin

evidence on the effectiveness and usage of long-term anticoagulant therapy after acute thromboembolic limb ischaemia is very sparse. This study correlated medical events with administration of warfarin.. during a three-month audit in 1996, 287 patients with embolism or thrombosisin situ survived for 30 days, and 214 (75%) were reviewed by questionnaires returned from clinicians throughout the United Kingdom. Minimum follow-up was two years.. thirty-five per cent had died. Recurrent acute limb ischaemia was reported in 11%, arterial intervention in 11%, and major amputation in 12%. Warfarin was given initially to 57% patients, but at follow-up only 43% were still taking warfarin (p<0. 05); reasons for stopping anticoagulation were often unknown. Recurrent limb ischaemia was less common in patients given warfarin initially (7% versus 17%) and still taking warfarin (3% versus 19%) -p;<0.05. Amputation was also less common in patients given warfarin initially (5% versus 21%) and still on warfarin (3% versus 21%) -p;<0.05.. long-term oral anticoagulation was associated with reduced risk of recurrent limb ischaemia and amputation, but more research is needed to define the benefits and risks, especially for thrombosisin situ. Clinicians should give clear advice about anticoagulation when patients are discharged from hospital.

Topics: Adult; Aged; Aged, 80 and over; Amputation, Surgical; Anticoagulants; Female; Follow-Up Studies; Humans; Ischemia; Leg; Male; Middle Aged; Surveys and Questionnaires; Thromboembolism; Warfarin

To evaluate in a group of seriously diseased patients with nonreconstructable chronic critical leg ischemia (CLI), treated by a combination of i.v. hydroxyethylrutosides (HR)* and oral anticoagulation (AC) by warfarin, the short-term effects on the cutaneous microvascular blood perfusion of the soles of feet and especially the long-term clinical outcome in terms of amputation and death.. A retrospective comparison between two groups of patients, HR + AC and a comparable reference group, fulfilling the same inclusion and exclusion criteria corresponding to the definition of CLI according to the Second European Consensus Document (1991). Clinical follow-up in both groups was made after 1, 3, 6, 12, and 24 months.. Patients were examined at university departments of clinical physiology with special interest in peripheral vascular disease, in cooperation with colleagues at university departments of surgery, internal medicine and dermatology of Karolinska Hospital, Södersjukhuset and Huddinge Hospital.. A total of seventy patients with CLI according to the definition of the Second European Consensus Document, 1991, ie, besides severe rest pain or ischemic lesions also a toe blood pressure < 30 mg Hg. Group with HR + anticoagulation (AC): 42 patients (19 diabetics, 23 nondiabetics). Reference group: 28 patients (18 diabetics, 10 nondiabetics). For distribution of age and toe blood pressure at baseline, see Table I.. Therapy group: besides ordinary standard therapy, daily HR infusions for a mean period of 3.6 weeks + oral anticoagulation continued to the end of the study at 24 months. A comparable reference group on the same basic therapy but without the combination HR + AC. PARAMETERS IN EVALUATION: Short-term parameters: clinical data, skin temperature, and fluorescein imaging. Long-term outcome: amputation or death.. Short-term and long-term results with HR + AC indicated that patients with severe CLI and very poor prognosis benefited in terms of survival and limb salvage from initial therapy with HR infusion combined with long-term oral anticoagulation. Results of this combined treatment seem at least comparable with those with i.v. prostacyclin analogies.

Topics: Administration, Oral; Aged; Amputation, Surgical; Anticoagulants; Arteriosclerosis; Blood Pressure; Cardiovascular Agents; Contrast Media; Diabetic Angiopathies; Drug Therapy, Combination; Fluorescein; Follow-Up Studies; Foot; Humans; Hydroxyethylrutoside; Infusions, Intravenous; Ischemia; Leg; Longitudinal Studies; Microcirculation; Prognosis; Retrospective Studies; Skin Temperature; Survival Rate; Treatment Outcome; Warfarin

Polytetrafluoroethylene (PTFE) prosthetic bypasses in the lower extremity have poor patency rates, particularly in limb salvage cases. Patency and limb salvage rates of PTFE bypasses supplemented by distal interposition vein cuffs were assessed in patients requiring revascularization for critical limb ischemia, in the absence of a suitable autologous saphenous vein. Between October 1993 and April 1996, 163 patients underwent 185 infrainguinal bypasses. Forty-three limbs in 42 patients (12 women, 30 men; mean age 67 years) did not have a suitable autologous saphenous vein (24%) and had femoropopliteal (20) and infrapopliteal (23) bypasses performed. Patients were examined prospectively at 3-month intervals during the first year and at 6-month intervals thereafter to determine graft patency and limb salvage. Postoperative anticoagulation with warfarin was used in 26 patients. Indications for operation included limb salvage in 41 extremities (21 rest pain/ulceration or gangrene, 20 rest pain alone), and disabling claudication in two. Patients were followed clinically for 2-30 months (mean 10 months). Cumulative 2-year life-table patencies for all grafts, femoropopliteal and infrapopliteal bypasses were 64%, 75% and 62%, respectively. Previous primary patencies at the authors' institution for PTFE bypasses without vein cuffs were 35%, 46% and 12% for the same categories. Cumulative life-table limb salvage for all PTFE/vein cuff bypasses in the present series was 76% compared with 37% in previous PTFE bypasses without vein cuffs. Adjunctive use of distal interposition vein cuffs improves prosthetic graft patency, while producing satisfactory limb salvage. Postoperative anticoagulation did not influence graft patency. PTFE/vein cuff for lower-extremity revascularization shows good 2-year patency and is an acceptable alternate conduit in patients with critical limb ischemia when autologous saphenous vein is absent.

Topics: Aged; Anticoagulants; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Female; Femoral Artery; Follow-Up Studies; Humans; Ischemia; Leg; Life Tables; Male; Polytetrafluoroethylene; Popliteal Artery; Prospective Studies; Time Factors; Vascular Patency; Veins; Warfarin

To illustrate a case of peripheral retinal neovascularization (Eales disease) in a patient who tested positive for the factor V Leiden mutation.. A 42-year-old woman had a 1-week history of blurred vision in her right eye. Her medical history was remarkable for a cerebrovascular accident. Ophthalmoscopy of the right eye disclosed a mild vitreous hemorrhage and a ridge of retinal neovascularization in the temporal periphery. The left fundus showed evidence of temporal retinal ischemia. A laboratory evaluation for hypercoagulability was positive for factor V Leiden mutation.. Peripheral scatter laser photocoagulation was applied to the ischemic retina, and the neovascularization regressed. The patient began taking warfarin sodium to prevent further thrombotic events.. A laboratory evaluation for coagulopathy, including the factor V Leiden mutation, should be added to the examination of patients with Eales disease, especially individuals with a history of a previous thrombotic event.

Topics: Adult; Anticoagulants; Factor V; Female; Fluorescein Angiography; Fundus Oculi; Humans; Ischemia; Laser Coagulation; Mutation; Retinal Neovascularization; Retinal Vessels; Vasculitis; Vitreous Hemorrhage; Warfarin

Catastrophic antiphospholipid antibody syndrome, reported in a minority of patients with circulating antiphospholipid antibodies, is characterized by widespread vascular occlusions. The term "catastrophic" has been used to describe the severity of symptomatology, sometimes leading to death. We describe a girl aged 11 years, fulfilling diagnostic criteria for systemic lupus erythematosus, with recurrent episodes of thromboembolic phenomena involving lung and skin, complicated with disseminated intravascular coagulation. Treatment with warfarin ultimately resulted in effective control of the disease.

Topics: Anticoagulants; Antiphospholipid Syndrome; Child; Disseminated Intravascular Coagulation; Female; Fingers; Humans; Ischemia; Lupus Erythematosus, Systemic; Warfarin

Topics: Anticoagulants; Aortic Arch Syndromes; Cerebrovascular Disorders; Diabetes Complications; Diabetic Angiopathies; Female; Hemiplegia; Humans; Ischemia; Leg; Middle Aged; Postoperative Complications; Warfarin

Activated protein C resistance caused by factor V Leiden is an important thrombophilia disorder which predisposes to venous thromboembolism. Some studies also suggest a role in the pathogenesis of arterial thrombosis and atherosclerosis. The authors have investigated the prevalence of activated protein C resistance and factor V Leiden in a series of 45 patients with peripheral vascular disease. Twelve patients were receiving warfarin. The activated protein C resistance ratios were significantly lower in the group of 33 non-warfarinized patients with peripheral vascular disease (median 2.82 (range 1.36-3.83)) compared with 33 age- and sex-matched controls (median 2.97 range 2.24-4.11); P<0.005; Wilcoxon rank sum). Eight patients (24%) had activated protein C resistance (ratio <2.2). The prevalence of factor V Leiden in patients with peripheral vascular disease was 17.8% (8/45). This is significantly increased compared with the local population and UK published frequency of 3.5% for this genotype. The presence of factor V Leiden did not affect the late outcome of arterial reconstructive surgery in terms of graft patency (P=0.5, Fisher's Exact test).

Topics: Aged; Arteriosclerosis; Blood Coagulation Tests; Enzyme Activation; Factor V; Female; Graft Occlusion, Vascular; Humans; Ischemia; Leg; Male; Middle Aged; Protein C; Reoperation; Risk Factors; Warfarin

The aetiology of non-arteritic ischaemic optic neuropathy (ION) is multifactorial with local anatomical and systemic haemodynamic abnormalities both playing a role. A careful search for treatable vascular disease risk factors is required to allow rational therapy, to optimise the visual prognosis and to allow new insights into pathogenesis. We describe 7 cases in which there was an associated thrombophilic (prothrombotic) state; 4 had deficiencies of the physiological anticoagulants proteins C and S and antithrombin III and 2 had anti-phospholipid antibody (lupus anticoagulant) syndromes. A further patient had reduced levels of the physiological fibrinolytic agent tissue plasminogen activator (t-PA). In 5 patients other risk factors for small vessel occlusive disease were also present, and 4 had recurrent episodes of ION in the same eye. The visual prognosis in these patients may be improved by anticoagulation with warfarin.

Topics: Adult; Aged; Antithrombin III Deficiency; Blood Coagulation Disorders; Female; Humans; Ischemia; Lupus Coagulation Inhibitor; Male; Middle Aged; Optic Nerve; Optic Nerve Diseases; Prognosis; Protein C Deficiency; Protein S Deficiency; Tissue Plasminogen Activator; Warfarin

This study was performed to clarify the role of intraarterial thrombolytic therapy (IATT) in the management of acute lower extremity ischemia.. A retrospective review of 77 patients undergoing 84 courses of high-dose regional urokinase IATT from July 1981 to June 1991 was performed. The group included patients with acute thrombosis of lower extremity bypass grafts (n = 48) or native arteries (n = 36), presenting with ischemic but viable limbs, minimal or no motor dysfunction, and an absence of muscle rigor or compartment syndrome. The data were then examined individually by site of thrombosis to evaluate patient selection for IATT.. Complete lysis, complications (either distal thromboembolism or bleeding), and early limb loss occurred in 59.5%, 11%, and 6% of infusions, respectively. IATT precluded the need for operative intervention in 49% of acutely ischemic limbs. When surgery was required, successful IATT precisely localized responsible lesions and reduced the magnitude of operation. A subset of 13 patients were identified in whom either no intrinsic abnormality or poor runoff were evident after lysis and were treated with anticoagulation alone.. These data show IATT to be especially suitable for thrombosis of native iliac or femoropopliteal arteries and infrainguinal vein grafts. IATT serves primarily as an adjunct in management of acute lower extremity ischemia. After successful IATT, subsequent therapy can be tailored to the anatomic cause of thrombosis.

Topics: Femoral Artery; Graft Occlusion, Vascular; Humans; Iliac Artery; Infusions, Intra-Arterial; Ischemia; Leg; Popliteal Artery; Retrospective Studies; Thrombolytic Therapy; Thrombosis; Urokinase-Type Plasminogen Activator; Warfarin

The effect of anticoagulation upon renal edema and plasma protein accumulation in acute ischemic renal damage was studied. Rats were subjected to unilateral renal artery occlusion for 60 min and 15 min of reflow. The kidney weight and the content of 125-I-fibrinogen and 131-I-albumin, injected 24 h priorly, were measured and the renal morphology studied. Groups of rats were pretreated with a heparin analogue with low anticoagulant effect, standard heparin, warfarin or saline. A marked increase in fibrinogen and albumin content and of the weight of the damaged kidney was noted. Heparin and warfarin both significantly attenuated these changes, whereas the heparin analogue did not. Microscopically, fibrin-positive material was seen in the peritubular capillaries, vasa recta and in the tubules of rats pretreated with saline or the heparin analogue, but not in rats pretreated with heparin or warfarin. The results support the hypothesis that fibrin deposition in the kidney is of importance for the development of renal edema in this model of ischemic renal damage.

Topics: Animals; Blood Pressure; Edema; Female; Fibrinogen; Heparin; Ischemia; Kidney; Kidney Diseases; Rats; Rats, Inbred Strains; Renal Artery; Renal Circulation; Serum Albumin; Warfarin

Topics: Aspirin; Humans; Ischemia; Leg; Multicenter Studies as Topic; Randomized Controlled Trials as Topic; Thrombolytic Therapy; Vascular Patency; Warfarin

To identify risk factors for lower limb loss after arterial embolectomy a cohort of 1189 patients was studied. Detailed data were obtained for 165 patients who underwent a major amputation within 30 days of embolectomy and for 165 matched controls. The amputation risk was increased in patients with two or more myocardial infarctions (odds ratio (OR) 3.1, 95 per cent confidence interval (CI) 0.8-11.2), chronic ischaemia (OR 2.1, CI 0.9-4.9), long duration of symptoms (OR 4.3, CI 1.9-9.6, for greater than or equal to 25 h versus less than or equal to 6 h) or postoperative heart failure (OR 3.4, CI 1.8-6.5). Reduced risks were found in association with acute myocardial infarction (OR 0.3, CI 0.1-0.9) and postoperative anticoagulation treatment with warfarin (OR 0.3, CI 0.1-0.9). The independent prognostic value of chronic ischaemia and symptom duration, and the beneficial effect of postoperative anticoagulation gained additional support in multivariate analysis. We conclude that the risk of early amputation after arterial embolectomy or thrombectomy can be predicted by several clinical characteristics.

Topics: Acute Disease; Adult; Aged; Aged, 80 and over; Amputation, Surgical; Arterial Occlusive Diseases; Case-Control Studies; Cohort Studies; Female; Heart Arrest; Humans; Ischemia; Leg; Male; Middle Aged; Myocardial Infarction; Postoperative Complications; Risk Factors; Warfarin

Episodic cerebro or retinovascular ischemic events without apparent cause occur in patients with cancer. We report a patient in remission from lymphoma whose multiple episodes of presumed ocular ischemia occurred in the setting of a circulating lupus anticoagulant. Symptoms resolved following therapy with Warfarin.

Topics: Antineoplastic Combined Chemotherapy Protocols; Eye; Humans; Ischemia; Lupus Coagulation Inhibitor; Lymphoma, Large B-Cell, Diffuse; Male; Middle Aged; Scotoma; Vision, Monocular; Warfarin

In cases of ischemic extremities and diabetes mellitus, the trauma on finger and toe is very intractable. For such injuries amputation of extremity is indicated very often because of severe necrosis. The number of such cases has been increasing recently because many cases of these patients have arteriosclerotic arterial occlusion and diabetes mellitus, and these are correlated with the changes of aging. The number of cases of Buerger's disease has been also increasing and it is another etiology of intractable trauma in ischemic extremity. The repeated hyperbaric oxygenation, sympathetic block, warfarin therapy and insulin bath with bubbling of hyperbaric oxygen, were applied to has been of such necrosis. By these procedures, the rate of amputation of extremity decreasing. It was concluded that the surgical reconstruction of artery for ischemic extremity has never any meaning as the therapy of such intractable injuries, if blood flow in the peripheral tissue is not kept physiologically, before vascular reconstruction. In order to increase peripheral tissue circulation, the hyperbaric oxygenation, sympathetic block and warfarin therapy wer performed in many cases and these methods were very effective for intractable injuries with severe necrosis.

Topics: Adult; Aged; Arteriosclerosis Obliterans; Diabetic Angiopathies; Female; Finger Injuries; Humans; Hyperbaric Oxygenation; Ischemia; Male; Middle Aged; Necrosis; Raynaud Disease; Thromboangiitis Obliterans; Toes; Warfarin

The anticoagulant, warfarin, has been reported to be effective as treatment for navicular disease in horses. Since other forms of treatment for this disease are palliative, this new anticoagulant therapy has become widely employed. Despite the fact that initiation of anticoagulant therapy is relatively simple, attending veterinary practitioners should be aware that careful monitoring of this therapy is required for both safety and efficacy. Navicular disease is an example of equine thrombotic disease, and the goal of warfarin therapy is the prevention of new thrombus formation, while at the same time preserving haemostasis. This paper presents a review of the mechanisms of action of warfarin, its beneficial effects, its potential for toxicity in horses, and the interaction of warfarin and other drugs. Laboratory monitoring of the therapy and vitamin K-1 treatment in case of overdosing are discussed.

Topics: Animals; Blood Coagulation Tests; Coumarins; Drug Interactions; Drug Labeling; Horse Diseases; Horses; Ischemia; Tarsal Bones; Warfarin

Heparin sodium-induced thrombosis is insidious and difficult to diagnose. If untreated, it results in death or major amputation. We have treated seven patients with thromboses resulting from platelet aggregation induced by heparin. Four patients had acute arterial ischemia of the lower extremity, venous gangrene developed in two, and one patient had an occluded autogenous vein femoral popliteal bypass in the immediate postoperative period. The platelet count was noticeably reduced in affected patients. White platelet thrombi were noted in four patients, three of whom had acute arterial occlusion. A white thrombus was the cause of immediate failure of a femoral popliteal graft. Electron microscopic examination of these thrombi demonstrated predominantly fibrin platelet aggregates with an occasional entrapped WBC and a rare RBC. All patients receiving heparin therapy must have platelet counts performed regularly. If thrombocytopenia is detected, platelet aggregation studies are indicated. When abnormal platelet aggregation is noted, heparin therapy should be reversed with protamine sulfate and the patient treated with low-molecular-weight dextran and warfarin sodium.

Topics: Aged; Blood Platelets; Dextrans; Female; Heparin; Humans; Ischemia; Leg; Male; Middle Aged; Platelet Aggregation; Thrombocytopenia; Thrombophlebitis; Thrombosis; Warfarin

Topics: Aspirin; Brain; Cerebrovascular Disorders; Dipyridamole; Fibrinolytic Agents; Heparin; Humans; Intracranial Embolism and Thrombosis; Ischemia; Sulfinpyrazone; Warfarin

Arterial emboli were extracted from 79 patients between 1955 and 1963 with polyethylene catheter suction systems and/or retrograde flushing and from 149 patients between 1963 and 1973 with Fogarty catheters. The Fogarty-era patients were older, had a greater incidence of ischemic heart disease, and presented with a greater degree of preoperative peripheral ischemia. The limb salvage rate of 87 percent after Fogarty catheter embolectomy was not statistically different from the salvage rate of 79 percent after suction catheter embolectomy, but the number of limbs with distal pulses postoperatively was significantly greater after Fogarty treatment, 64 vs. 42 percent. Delay in treatment and the presence of prior occlusive vascular disease adversely affected results in both eras. The in-hospital embolic recurrences occurred in 9 percent of the patients anticoagulated postoperatively and in 31 percent of those not anticoagulated. Heparin and warfarin were equally effective in preventing recurrences, but wound complications were seen in 33 percent of the heparinized patients, compared with 7 percent of those receiving warfarin and 4 percent of those not anticoagulated.

Topics: Aged; Aortic Diseases; Arm; Catheterization; Embolism; Femoral Artery; Follow-Up Studies; Gangrene; Heparin; Humans; Iliac Artery; Ischemia; Leg; Popliteal Artery; Postoperative Care; Recurrence; Warfarin

Topics: Aorta, Abdominal; Dextrans; Endarterectomy; Female; Femoral Artery; Follow-Up Studies; Hematoma; Hemorrhage; Humans; Intermittent Claudication; Ischemia; Leg; Male; Popliteal Artery; Postoperative Complications; Pulmonary Embolism; Saphenous Vein; Surgical Wound Infection; Thrombosis; Vascular Surgical Procedures; Warfarin

Topics: Adult; Age Factors; Aged; Angiography; Blood Vessel Prosthesis; Diabetes Complications; Dicumarol; Female; Femoral Artery; Fluorocarbon Polymers; Follow-Up Studies; Heparin; Humans; Iliac Artery; Intermittent Claudication; Ischemia; Leg; Male; Methods; Middle Aged; Popliteal Artery; Postoperative Complications; Sex Factors; Thrombosis; Transplantation, Autologous; Transplantation, Homologous; Vascular Diseases; Veins; Warfarin

The outcome of 185 consecutive autogenous vein bypass grafts for femoro-popliteal occlusions carried out between January 1962 and June 1968 has been reviewed. One patient died at operation and 21 late deaths have occurred since. The overall five-year patency was 61.5%, but was much lower when the popliteal-tibial runoff arteries were diseased. Distal anastomosis of the graft to the popliteal artery below the level of the knee joint also impaired the results, and if this was performed with a graft of minimal diameter less than 5 mm. sustained patency was obtained in only a quarter of the limbs. Nevertheless, where major amputation was imminent owing to advanced ischaemia three out of four limbs were salvaged.

Topics: Adult; Aged; Arteriosclerosis; Electrocardiography; Female; Femoral Artery; Follow-Up Studies; Humans; Ischemia; Male; Middle Aged; Phenindione; Popliteal Artery; Postoperative Complications; Transplantation, Autologous; Vascular Diseases; Veins; Warfarin

Topics: Blood Coagulation; Blood Coagulation Factors; Blood Coagulation Tests; Cholesterol; Coronary Disease; Diet; Dietary Fats; Factor IX; Factor X; Ischemia; Kidney Diseases; Lipidoses; Pathology; Pharmacology; Phospholipids; Rats; Research; Warfarin