Abstract: Introduction: among patients with ischemic stroke (IS), more than 17% has atrial fibrillation (AF). The active application of aspiration thrombectomy (AT), in addition to thrombolytic therapy (TLT), can significantly improve functional outcome, prognosis and survival of patients with IS. The main method of preventing of IS in patients with nonvalvular AF today is still an anticoagulant therapy, but percutaneous transcatheter occlusion of the left atrium appendage (LAA) can be an alternative method, especially if anticoagulant therapy is contraindicated or ineffective. Aim: was to demonstrate results of a complex staged treatment of an age-related patient with nonvalvular atrial fibrillation, complicated by the development of cardioembolic ischemic stroke while taking anticoagulants. Material and methods: a clinical observation of a 81-year-old patient delivered to the hospital with a clinical manifestation of ischemic stroke in the “therapeutic window”, with a history of persistent AF and taking anticoagulants, is presented. After conservative therapy - a regression of neurological symptoms was achieved. Three days after - negative dynamics in the clinical picture with development of aphasia and right-sided hemiplegia. Multispiral computed tomography with contrast (MSCT-A): occlusion of M2 segment of the left middle cerebral artery (MCA). Patient underwent aspiration thrombectomy with complete restoration of blood flow and regression of neurological symptoms. After 2 months from the episode of IS, patient underwent implantation of occlude in the left atrial appendage as a prophylaxis of re-embolism, followed by the abolition of warfarin. Results: a senile patient returned to normal life and self-care (assessed using the modified Rankin scale 1). During next 13 months patient had no major adverse cardiac events (MACE) or significant bleeding and all that shows that occlusion of LAA is effective. Conclusions: in the early period of ischemic stroke, isolated aspiration thrombectomy is the operation of choice in patients with atrial fibrillation and contraindication for thrombolytic therapy, and endovascular occlusion of the left atrial appendage can be the method of choice for secondary prevention of ischemic stroke. Further studies are required to assess applicability and reproducibility of the approach we have described in routine clinical practice. References 1. Hankey G.J. Stroke. The Lancet. 2017; 389 (10069): 641-654. https://doi.org/10.1016/S0140-6736(16)30962-X 2. Feigin V.L., Krishnamurthi R.V., Parmar P., et al; GBD Writing Group; GBD 2013 Stroke Panel Experts Group. Update on the Global Burden of Ischemic and Hemorrhagic Stroke in 1990-2013: The GBD 2013 Study. Neuroepidemiology. 2015; 45 (3):161-76. https://doi.org/10.1159/000441085 3. Savello AV, Voznjuk IA, Svistov DV, Babichev KN, Kandyba DV, Shenderov SV, Vlasenko SV, Shlojdo EA, Kachesov JeJu, Esipovich ID, Haritonova TV. Results of treatment of ischemic stroke using intravascular thromboembolectomy in conditions of regional vascular centers in a metropolis (St. Petersburg). Zhurnal nevrologii i psihiatrii im. C.C. Korsakova. 2018; 118 (12-2): 54-63. https://doi.org/10.17116/jnevro201811812254 4. Savello AV, Svistov DV, Sorokoumov VA. Endovascular treatments for ischemic stroke: Present status and prospects. Nevrologia, nejropsihiatria, psihosomatika. 2015; 7 (4): 42-49. https://doi.org/10.14412/2074-2711-2015-4-42-49 5. Saposnik G., Gladstone D., Raptis R., et al. Investigators of the Registry of the Canadian Stroke Network (RCSN) and the Stroke Outcomes Research Canada (SORCan) Working Group. Atrial fibrillation in ischemic stroke: predicting response to thrombolysis and clinical outcomes. Stroke. 2013; 44 (1): 99-104. https://doi.org/10.1161/STROKEAHA.112.676551 6. Lin H.J., Wolf P.A., Kelly-Hayes M., et al. Stroke severity in atrial fibrillation. The Framingham Study. Stroke. 1996; 27 (10): 1760-1764. https://doi.org/10.1161/01.str.27.10.1760 7. Pistoia F., Sacco S., Tiseo C., et al. The Epidemiology of Atrial Fibrillation and Stroke. Cardiol Clin. 2016; 34 (2): 255-268. https://doi.org/10.1016/j.ccl.2015.12.002 8. Aguilar M.I., Hart R., Pearce L.A. Oral anticoagulants versus antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no history of stroke or transient ischemic attacks. Cochrane Database Syst Rev. 2007; 18 (3): CD006186. https://doi.org/10.1002/14651858.CD006186.pub2 9. Kamel H., Healey J.S. Cardioembolic Stroke. Circ Res. 2017; 120 (3): 514-526. https://doi.org/10.1161/CIRCRESAHA.116.308407 10. Go A.S., Hylek E.M, Phillips K.A., et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001; 285 (18): 2370-2375. https://doi.org/10.1001/jama.285.18.2370 11. Demaerschalk B.M., Kleindorfer D.O., Adeoye O.M., et al. American Heart Association Stroke Council and Council on Epidemiology and Prevention. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke: A Statement for Healthcare Professionals From the American Heart Association/ American Stroke Association. Stroke. 2016; 47 (2): 581-641. https://doi.org/10.1161/STR.0000000000000086 12. Powers W.J., Rabinstein A.A., Ackerson T., et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019; 50 (12): 344-418 https://doi.org/10.1161/STR.0000000000000211 13. Bajwa R.J., Kovell L., Resar J.R., et al. Left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation. Clin Cardiol. 2017; 40 (10): 825-831. https://doi.org/10.1002/clc.22764 14. Kirchhof P., Benussi S., Kotecha D., et al. 2016 ESC Guidelines for the Management of Atrial Fibrillation Developed in Collaboration With EACTS. 2017; 70 (1): 50.
Abstract: In order to check the efficiency of pharmacological prophylaxis of venous thromboembolism in 500 patients with multiple injuries we weekly performed ultrasonography of lower limb veins from 3-5 days after the accident date. Patients were divided into two groups. There were 186 patients with prophylaxis with LMWH in the first group, other group included 314 patients which took single antiplatelet therapy. Thrombosis occured in 29 (15.6%) cases in the first group. In 19 (61.2%) limbs thrombosis defeated the common femoral vein and it was floating in 67.7% of cases. In the second group thrombosis was found in 165 (52.5%) patients. Mural (46%) and occlusive (35.3%) changes from the proximal border, not reaching the common femoral vein - (62%) were dominating. It was found that during fraxiparine treatment venous complications were 3.3 times less likely than with antiplatelet agents, however, 3.6 times increased the proportion of floating embologenic thrombosis. However, in these patients, the spread of the pathological process in the proximal direction noted in 2 times less, and the beginning of recanalization 1-2 weeks earlier and more effective restoration of the lumen. References 1. Van Hensbroek P.B., Haverlag R., Ponsen K.J. et al., Prevention of thrombosis in traumatology. Ned. Tijdschr. Geneeskd.2007; 4(151): 234-239. 2. Lippi G., Franchini M. Pathogenesis of venous thromboembolism: when the cup runneth over. Semin Thromb Hemost. 2008; 8(34):747-761. 3. Baeshko A.A. Risk i profilaktika venoznykh tromboembolicheskikh oslozhnenii v khirurgii [Risk and prophylaxis of venous thromboembolic complications in surgery] Khirurgiya. 2001; 4: 61-67 [In Russ]. 4. Anderson F.A., Spencer F.A. Risk factors for venous thromboembolism. Circulation. 2003;107: 33-38. 5. Geerts W.H., Jay R.M., Code K.I. et al. A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. N. Engl. J. Med. 1996; 335: 701-707. 6. Lazarenko V.A., Mishustin V.N. Pulmonary artery thromboembolism in patients with trauma. Angiol. Sosud. Khir. 2005; 11(4): 101-104. 7. Geerts W.H., Pineo G.F., Heit J.A. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004; 126(3): 338-400. 8. Giannadakis K., Leppek R., Gotzen L. et al. Thromboembolism complication in multiple trauma patients: an underestimated problem? Results of a clinical observational study of 50 patients. Chirurg. 2001;72:100-107. 9. Knudson M.M., Lewis F.R., Clinton A. et al. Prevention of venous thromboembolism in trauma patients. J. Trauma. 1994; 37:11-15. 10. Rogers F.B. Venous thromboembolism in trauma patients: a review. Surgery. 2001;130:74-78. 11. Kearon, C. Natural history of venous thromboembolism. Circulation. 2003;107(1):22-30. 12. Robinson D.M., Wellington K. Fondaparinux sodium: a review of its use in the treatment of acute venous thromboembolism. Am. J. Cardiovasc. Drugs. 2005; 5: 335-346. 13. Shchelokov A.L., Zubritskii V.F., Nikolaev K.N i dr. Kombinirovannaya venoznykh tromboembolicheskikh oslozhnenii u postradavshikh s perelomami proksimal'nogo otdela bedrennoi kosti [Combined prophylaxis of venous tromboembolic complications in patients with fracture of proximal part of femur]. Vestniktravmatologiii ortopedii. 2007;1:16-21 [In Russ]. 14. Asamov R.E., Tulyakov R.P., Muminov Sh.M. i dr. Bessimptomnye flebotrombozy nasledstvennaya trombofiliya u bol'nykh so skeletnoi travmoi [Asymptomatic phlebothrombosis and hereditary thrombophilia in patients with skeletal trauma]. Angiologiya i sosudistaya khirurgiya. 2008; 3:73-76 [In Russ]. 15. Kruger K., Wildberger J., Haage P. et al. Diagnostic imaging of venous disease: Part I: methods in the diagnosis of veins and thrombosis. Radiologe. 2008; 48 (10): 977-992. 16. Tomkowski W.Z., Davidson B.L., Wisniewska J. et al. Accuracy of compression ultrasound in screening for deep venous thrombosis in acutely ill medical patients. Thromb. Haemost. 2007; 97(2):191-194. 17. Savel'ev V.S. Venoznye trombozy i tromboemboliya legochnoi arterii (venoznye tromboembolicheskie oslozhneniya): Metod. rekomendatsii. V.S.Savel'ev [Venous trombosis and pulmonary embolism (venous tromboembolic complications )]. M., 2007: 20 s [In Russ]. 18. Balakhonova T.V. Sovremennye instrumental'nye metody diagnostiki tromboza: ul'trazvukovoe dupleksnoe skanirovanie. Profilaktika tromboembolicheskikh oslozhnenii v travmatologii i ortopedii [Modern instrumental diagnostics of trombosis: ultrasonic duplex scanning. Prophylaxis of thromboembolic complications in traumatology and orthopedics.]: materialy gor. simp., Moskva. 2003; 12-17 [In Russ]. 19. Utverzhdenie otraslevogo standarta vedeniya bol'nykh. Profilaktika tromboembolii legochnoi arterii pri khirurgicheskikh i inykh invazivnykh vmeshatel'stvakh: Prikaz Ministerstva zdravookhraneniya Rossiiskoi Federatsii №233 ot 09.06.2003 [Approval of medical treatment standarts. Prophylaxis of pulmonary embolism in surgical and other interventions: order of Ministry of Health of the Russian Federation №233 since 09.06.2003] [In Russ].
