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One hundred and twenty-two permanent pacemaker lead placements were performed by two physicians, utilizing a recently released peelaway sheath introducer with a splittable hemostatic valve. All introducers performed well and provided convenient bloodless surgical fields, as expected from the presence of a valve.
The hemostatic puncture closure device Angio-Seal is a quick, safe, and easy-to-use system, allowing rapid sealing of the vascular access site following coronary angiography and interventional procedures. It is advantageous for patients in whom early mobilization is desired and may therefore decrease hospital costs. Despite the documented low complication rate, there are some specific problems. Reporting on five cases, we describe problems in diagnosis and possible interventional therapy of Angio-Seal-associated complications such as stenosis, occlusion, or peripheral embolism. Our experience led to the concept of precise diagnosis in any patient with leg symptoms and early interventional treatment with the aim of complete removal of the intra-arterial parts of the Angio-Seal device. Any delay in diagnosis and treatment increases the risk of additional thrombotic occlusion. Spontaneous dissolution of the Angio-Seal sponge limits interventional possibilities of complete removal. Cathet. Cardiovasc. Intervent. 49:142-147, 2000.
We performed coagulation profiles including a complete blood count (CBC), prothrombin time (PT), activated partial thromboplastin time (aPTT), and quantitation of fibrinogen, antithrombin III (AT III), plasminogen, and fibrin/fibrinogen degradation products (FDP) on 73 cancer patients. All had solid tumors with clinically documented metastases. Eleven patients had strong clinical and laboratory evidence of disseminated intravascular coagulation (DIC). Fifty-five of the remaining 62 patients had no clinical evidence of serious hemorrhage or thrombosis at the time of testing. Thirty-one (50%) non-DIC patients had no abnormal clotting tests. Our data indicate that a majority of cancer patients, with or without hepatic involvement, are able to maintain normal or near normal hemostatic function in vitro until advanced stage of disease. Deviation from normal for PT, aPTT, or TT, depressed AT III activity, or increased FDP signal the presence of complicating pathophysiologic events such as DIC or cirrhosis. Diminution of fibrinogen level or AT III activity and elevation of FDP are more sensitive indicators of DIC than prolongation of PT, aPTT, or TT.
A patient with hypothyroidism had ingested aspirin and bled profusely following dental extraction. The only abnormalities noted on coagulation survey were a prolonged aspirin bleeding time and reduced retention of platelets on glass beads. Based on this index case, an additional 12 hypothyroid patients, on no medications, were evaluated for a mild bleeding disorder, including studies with aspirin challenge. The results indicate that thrombin-induced platelet serotonin release, following aspirin ingestion, was subnormal in most hypothyroid patients. However, only hypothyroid individuals with TSH levels of greater than 60 microU/ml have an increased hemostatic sensitivity to aspirin, as measured by the bleeding time test. These findings did not appear to result from decreased synthesis of the factor VIII-von Willebrand factor complex. As this drug is commonly ingested, the effects of aspirin on bleeding may explain the easy bruising and menorrhagia that occur in hypothyroid individuals.
Desmopressin acetate (DDAVP) is efficacious in patients with von Willebrand's disease. It additionally appears to have value in patients with uremic or aspirin-induced platelet dysfunction. We report here three patients with primary platelet defects who had previously experienced grossly inadequate hemostasis to whom we administered DDAVP. Each successfully underwent surgical procedures with DDAVP as the only hemostatic agent. Although the mechanism of these salutary effects is unclear, DDAVP may exert an influence directly on the endothelium independent of correcting abnormalities of the factor VIII:von Willebrand complex associated with von Willebrand's disease.
The isolation and partial characterization of a novel anticoagulant from the plasma of a patient with metastatic prostate cancer is described. The patient had a prolonged activated partial thromboplastic time, prothrombin time and thrombin time which did not correct by mixing with normal plasma. The reptilase time was normal and the prolonged thrombin time was corrected with protamine sulfate suggesting a heparin-like anticoagulant. A glycosaminoglycan anticoagulant (GAC) was isolated from the patient's plasma. The inhibitory activity of the GAC was destroyed by treatment with chondroitinase ABC. The GAC migrated on agarose gel electrophoresis between keratin sulfate and heparan sulfate. Purified GAC possessed only 2% (W/W) of the antithrombin III cofactor activity of porcine heparin. In assays using purified fibrinogen, the GAC was shown to directly inhibit fibrinogen proteolysis by thrombin. It is concluded that this glycosaminoglycan anticoagulant directly inhibits thrombin clotting of fibrinogen and is a new mechanism for abnormal hemostatic assays in cancer.
High-dose intravenous immunoglobulins (ivIG) were used in a 57-year-old patient with acquired von Willebrand disease in order to correct a hemostatic defect before pneumonectomy for lung carcinoma. IvIG induced a rapid and complete correction of factor VIII (F VIII) and von Willebrand factor (vWF) and allowed surgery without additional factor coverage. F VIII and vWF returned to baseline values within 10 days after ivIG.
Quantitative changes of hemostatic molecular markers were studied in patients with nephrotic syndrome. The plasma levels of fibrinopeptide A (FPA), thrombin-antithrombin III complex (TAT), products of thrombin activation, and fragment F1 + 2 (F1 + 2), a product of prothrombin activation, were measured by enzyme immunoassay in 21 patients with nephrotic syndrome and in 16 normal controls. The mean value of FPA was 17.5 +/- 7.5 ng/ml (mean +/- SD) in nephrotic patients and 4.5 +/- 0.3 ng/ml in normal controls (P < 0.02); F1 + 2 concentration was 1.4 +/- 0.3 ng/ml in nephrotic patients and 0.5 +/- 0.1 ng/ml in normal controls (P < 0.001); TAT level was 1.0 +/- 0.3 microgram/l in nephrotic patients and 0.2 +/- 0.1 microgram/l in normal controls (P < 0.05). These data indicated intravascular hemostasis activation. Based on these results, we propose that low antithrombin III level in nephrotic patients may be due to both urinary loss and intravascular consumption.
Transradial cardiac catheterization is an increasingly popular technique mainly because of the low vascular complication rate. We report a case of arm deep vein thrombosis that may be related to a common puncture site hemostasis technique. This complication supports the use of specific unilateral compression hemostatic systems following transradial procedures.
Glucosamine- and N-acetyl glucosamine-containing polymers are being used in an increasing number of biomedical applications, including in products for surface (topical) hemostasis. The studies presented here investigate the relationship between the structure (conformation) and function (activation of hemostasis) of glucosamine-based materials. Several polymer systems were studied, including fibers isolated from a microalgal source containing poly-N-acetyl glucosamine polymers that are organized in a parallel, hydrogen-bonded tertiary structure and can be chemically modified to an antiparallel orientation; and gel formulation derivatives of the microalgal fibers consisting of partially deacetylated (F2 gel) and fully deacetylated (F3 gel) polymers. Comparison of the properties of the poly-N-acetyl glucosamine fiber-derived materials with chitin, chitosan, and commercial chitosan-based products are presented. Several studies were performed with the glucosamine-based materials, including (1) an analysis of the ability of materials to activate platelets and turnover of the intrinsic coagulation cascade, (2) an examination of the viscoelastic properties of mixtures of platelet-rich plasma and the glucosamine-based materials via thromboelastography, and (3) scanning electron microscopic studies to examine the morphology of the glucosamine-based materials. The results presented demonstrate that hemostatic responses to the glucosamine-based materials studied are highly dependent on their chemical nature and tertiary/quaternary structure. The unique natural microalgal fibers were found to have strongly prohemostatic activity compared to the other materials studied.
Biology as a scientific discipline has relied heavily upon advances in chemistry and physics. An inherent danger in this relationship is the reduction of living phenomena to physico-chemical terms. Whitehead's 'Philosophy of Organism' is utilized to examine current methodologies within biology and to evaluate their appropriateness for future research. Hemostatic regulation is employed to illustrate the applications of organistic concepts to biological research. It is concluded that understanding of living entities and their properties as well as possibly life itself will require synthesis of the many analytical elements as informational structures.
The aim of the study was to compare in a single trial, using identical methodology, the pharmacokinetic properties and the effect on the hemostatic system of saruplase (unglycosylated scu-PA) and urokinase (glycosylated tcu-PA). Twenty-four patients with an acute myocardial infarction were either treated with saruplase (n = 12; 20 mg IV bolus followed by a 60 mg infusion for 60 minutes) or urokinase (n = 12; 1.5 million IU IV bolus followed by 1.5 million IU infusion for 60 minutes). Blood samples from saruplase-treated patients were analyzed for u-PA antigen and total u-PA and tcu-PA activities; those from urokinase-treated patients for u-PA antigen and tcu-PA activity. The effect of treatment on, including recovery of, plasma alpha2-antiplasmin, fibrinogen, and plasminogen was examined in both groups. The total clearance of urokinase (179 +/- 55 ml/min) is about half that of saruplase (406 +/- 154 ml/min), and the mean residence time of urokinase (59.1 +/- 22.5 minutes) is nearly twice that of saruplase (28.3 +/- 7.8 minutes), which results in a slower elimination of urokinase from plasma. Whether differences in the pharmacokinetic behavior of the unglycosylated saruplase and the glycosylated urokinase observed in this study are due to the difference in glycosylation or to other factors is not resolved. The systemic effect of saruplase on alpha2-antiplasmin, fibrinogen, and plasminogen is similar to that of urokinase, although retarded.
Background: Epidemiological studies has shown that increased fibrinogen and factor VIIc are two independent risk factors for cardiovascular disease (CVD). Postmenopausal women have a higher incidence of CVD than premenopausal women; one possible explanation is the increase of fibrinogen. Purpose: This study was undertaken to evaluate the influence of oral contraceptive pill use and postmenopausal status on coagulation factors in ethnic Chinese women. Patients and methods: This study included 1402 women aged 40-55 years, with 288 premenopausal women taking oral contraceptives and 364 postmenopausal women. All subjects underwent blood examination of prothrombin time, activated partial thromboplastin time, fibrinogen, factor VIIc, factor VIIIc, plasminogen, and antithrombin III. Results: Data show that oral contraceptives users had a significant increase in plasminogen (91.7 +/- 40.7 vs. 80.0 +/- 26.5%; p < 0.01), while the levels of other hemostatic parameters were similar to non-contraceptive pill users. Postmenopausal women also had higher levels of plasminogen (113 +/- 36.2 vs. 108.7 +/- 30.7%; p = 0.06); the other parameters also show no statistical significance. Conclusions: Contrary to previous reports, which show elevation of fibrinogen and antithrombin III in menopause and in pill users, this study shows that only plasminogen levels exhibit a statistically significant contraceptive trend in Chinese women. Whether racial difference may account for the discrepancy in the present results needs further evaluation.
This review focuses on the hemorrhagic and thrombotic complications sometimes associated with the most common renal disorders in children. A Medline search of the literature was conducted from 1966 to January 1995, using combinations of key words appropriate for each disorder. Additional references were located through the bibliographies of the publications and recent journals were searched independently. The most common renal disorders with hemostatic complications in children were: renal vein thrombosis (268 children in 80 publications), hemolytic uremic syndrome (473 children in 29 publications), nephrotic syndrome (4,158 children in 51 publications), renal transplantation (3,976 children in 14 publications), glomerulonephritis (20 publications), end-stage renal disease, and dialysis (22 publications). The age distribution, clinical presentation, etiology, diagnosis, treatment, and outcome of the affected children were analyzed for each disorder. Children with inherited pre-thrombotic disorders usually do not present during childhood unless there is a secondary risk factor. Similarly, most children with renal disease do not develop thromboembolic complications. Therefore, when a child with a renal disorder develops a thromboembolic event, evaluation for an inherited pre-thrombotic disorder should be seriously considered. Guidelines for the use of heparin and warfarin in these children (both therapeutically and prophylactically) are given. At this time, the risk/benefit of thrombolytic therapy in children is not known and a general recommendation for thrombolytic therapy cannot be made.
Portal azygos disconnection, using vein ligatures and a circumferential hemostatic suture of the gastric wall at the level of the upper pole, is a simple and a rapid technique that effectively controls bleeding from esophagogastric varices. Its low mortality rate in emergency cases or poor-risk patients can be of great benefit to patients who have not responded to conservative therapy, including tamponade and vein sclerosis. In this article, we conclude that the long-term results of this operation demonstrate that it can also be used in elective cases, especially in patients with Child's "C" classification. These patients with advanced cirrhosis have a very low survival rate (no more than 5 years) yet they can benefit from this portal disconnection since this procedure does not alter the portal hemodynamics and, consequently, does not induce chronic encephalopathy.
Four different plasma-derived concentrates composed of coagulation factor VIII (FVIII) and von Willebrand factor (vWF) of varying quality (Hemate-P, Behring; Profilate, Alpha; and F VIII-VHP-vWF, C.R.T.S Lille), or almost purified vWF (Facteur Willebrand, C.R.T.S Lille) and one recombinant F VIII concentrate (Recombinate, Baxter) were given, in doses of 30-60 IU VIII: C/kg or 70-110 IU RCof/kg, to five patients with von Willebrand's disease type III, in order to evaluate the role of the vWF in factor F VIII concentrates. All plasma concentrates except Profilate had a multimeric vWF pattern almost similar to that of normal plasma. Bleeding time (b.t.), VIII: C, vWF:Ag, ristocetin cofactor activity, and multimeric pattern of the plasma-vWF were followed for 72 h. Both Duke b.t. and the multimeric pattern in plasma normalized after infusion of Hemate-P, F VIII-VHP-vWF, and Facteur Willebrand and, to a lesser extent, after Profilate. As expected, in response to Recombinate there was no effect on primary hemostasis, and the half-life of F VIII procoagulant activity (VIII: C) was very short. Normalization of the vWF is important not only for improving the primary hemostasis, but also for maintaining the plasma F VIII concentration on a high level, both by reducing the elimination rate of infused F VIII and via a secondary release of endogenous F VIII. If a prompt hemostatic effect is required, we recommend a concentrate containing both F VIII and all vWF multimers, but for prophylactic treatment, pure vWF may be used.
A longitudinal study of hemostatic function was carried out on 100 Singaporean acceptors using Norplant-2 rods for contraception. The results at the end of three years indicate a possible increased predisposition to thrombosis, as evidenced by significant increases in platelet count and aggregability. The prothrombin time (PT) and activated partial thromboplastin time (APTT) continued to remain shortened at the end of three years of use. There was also a general fall in most of the vitamin K coagulation factors. There is thus still an indication of a possible enhanced potential for hypercoagulation at the end of three years of Norplant-2 rod use.
Women using the Norplant-2 rod system in Singapore have been shown to have a change in their hemostatic function. There is a decrease in vitamin K dependent factors II, VII and a tendency toward lowered fibrinolytic activity after use of Norplant-2 rods. There was also an increase in platelet number and accelerated-platelet aggregation. These changes are similar to those seen with the Norplant six-capsule system and it would appear that both systems do not activate the coagulation system or enhance a state of hypercoagulation. On removal of the Norplant-2 rods at the end of 5 years, the significant changes seen in hemoglobin function observed with Norplant-2 rod use remained.