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Murao S, Umemura Y, Mori H, Seki Y, Ikezoe T, Okamoto K, Fujimi S, Yamakawa K. Prevalence and clinical impact of disseminated intravascular coagulation in acute aortic dissection: a nationwide cohort study. Res Pract Thromb Haemost 2025; 9:102656. [PMID: 39882555 PMCID: PMC11774824 DOI: 10.1016/j.rpth.2024.102656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 11/09/2024] [Accepted: 11/21/2024] [Indexed: 01/31/2025] Open
Abstract
Background Acute aortic dissection is a life-threatening cardiovascular emergency with high mortality rates. Disseminated intravascular coagulation (DIC) is a critical complication in patients with acute aortic dissection; however, its incidence and impact on outcomes remain inconclusive. Objectives This study aimed to evaluate DIC prevalence and prognosis in patients with aortic dissection. Methods We conducted a multicenter retrospective cohort study using data from the Japan Medical Data Center claims database between 2014 and 2022. DIC was diagnosed based on the criteria of the Japanese Association for Acute Medicine (JAAM-2) and the International Society on Thrombosis and Haemostasis (ISTH). We compared the in-hospital mortality between patients with and without DIC and assessed the impact of coagulopathy using various coagulation profiles. Results Among the 3037 patients, 40% underwent surgery and 60% did not undergo surgery. The prevalence rates of JAAM-2 DIC and ISTH DIC were 21% and 9.4%, respectively. In-hospital mortality was significantly higher in the DIC group than in the non-DIC group, and this trend was consistently observed in the surgery and nonsurgery groups. Increased DIC scores correlated with higher in-hospital mortality. With the progression of coagulopathy, characterized by thrombocytopenia, elevated prothrombin time-international normalized ratio, prolonged activated partial thromboplastin time, increased D-dimer, and decreased fibrinogen levels, in-hospital mortality also increased. Conclusion The presence of DIC, as identified by both the JAAM-2 and ISTH criteria, was associated with increased in-hospital mortality in patients with acute aortic dissection. Therefore, further studies are needed to improve the clinical outcomes of these patients.
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Affiliation(s)
- Shuhei Murao
- Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Yutaka Umemura
- Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Hirotaka Mori
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yoshinobu Seki
- Department of Hematology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Takayuki Ikezoe
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kohji Okamoto
- Department of Surgery, Kitakyushu City Yahata Hospital, Fukuoka, Japan
| | - Satoshi Fujimi
- Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Kazuma Yamakawa
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
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Wada T, Gando S. Phenotypes of Disseminated Intravascular Coagulation. Thromb Haemost 2024; 124:181-191. [PMID: 37657485 PMCID: PMC10890912 DOI: 10.1055/a-2165-1142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 08/30/2023] [Indexed: 09/03/2023]
Abstract
Two phenotypes of disseminated intravascular coagulation (DIC) are systematically reviewed. DIC is classified into thrombotic and fibrinolytic phenotypes characterized by thrombosis and hemorrhage, respectively. Major pathology of DIC with thrombotic phenotype is the activation of coagulation, insufficient anticoagulation with endothelial injury, and plasminogen activator inhibitor-1-mediated inhibition of fibrinolysis, leading to microvascular fibrin thrombosis and organ dysfunction. DIC with fibrinolytic phenotype is defined as massive thrombin generation commonly observed in any type of DIC, combined with systemic pathologic hyperfibrinogenolysis caused by underlying disorder that results in severe bleeding due to excessive plasmin formation. Three major pathomechanisms of systemic hyperfibrinogenolysis have been considered: (1) acceleration of tissue-type plasminogen activator (t-PA) release from hypoxic endothelial cells and t-PA-rich storage pools, (2) enhancement of the conversion of plasminogen to plasmin due to specific proteins and receptors that are expressed on cancer cells and endothelial cells, and (3) alternative pathways of fibrinolysis. DIC with fibrinolytic phenotype can be diagnosed by DIC diagnosis followed by the recognition of systemic pathologic hyperfibrin(ogen)olysis. Low fibrinogen levels, high fibrinogen and fibrin degradation products (FDPs), and the FDP/D-dimer ratio are important for the diagnosis of systemic pathologic hyperfibrin(ogen)olysis. Currently, evidence-based treatment strategies for DIC with fibrinolytic phenotypes are lacking. Tranexamic acid appears to be one of the few methods to be effective in the treatment of systemic pathologic hyperfibrin(ogen)olysis. International cooperation for the elucidation of pathomechanisms, establishment of diagnostic criteria, and treatment strategies for DIC with fibrinolytic phenotype are urgent issues in the field of thrombosis and hemostasis.
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Affiliation(s)
- Takeshi Wada
- Department of Anesthesiology and Critical Care Medicine, Division of Acute and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Satoshi Gando
- Department of Anesthesiology and Critical Care Medicine, Division of Acute and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Therapeutic Strategies for Disseminated Intravascular Coagulation Associated with Aortic Aneurysm. Int J Mol Sci 2022; 23:ijms23031296. [PMID: 35163216 PMCID: PMC8836167 DOI: 10.3390/ijms23031296] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/05/2022] [Accepted: 01/22/2022] [Indexed: 01/22/2023] Open
Abstract
Aortic aneurysms are sometimes associated with enhanced-fibrinolytic-type disseminated intravascular coagulation (DIC). In enhanced-fibrinolytic-type DIC, both coagulation and fibrinolysis are markedly activated. Typical cases show decreased platelet counts and fibrinogen levels, increased concentrations of fibrin/fibrinogen degradation products (FDP) and D-dimer, and increased FDP/D-dimer ratios. Thrombin-antithrombin complex or prothrombin fragment 1 + 2, as markers of coagulation activation, and plasmin-α2 plasmin inhibitor complex, a marker of fibrinolytic activation, are all markedly increased. Prolongation of prothrombin time (PT) is not so obvious, and the activated partial thromboplastin time (APTT) is rather shortened in some cases. As a result, DIC can be neither diagnosed nor excluded based on PT and APTT alone. Many of the factors involved in coagulation and fibrinolysis activation are serine proteases. Treatment of enhanced-fibrinolytic-type DIC requires consideration of how to control the function of these serine proteases. The cornerstone of DIC treatment is treatment of the underlying pathology. However, in some cases surgery is either not possible or exacerbates the DIC associated with aortic aneurysm. In such cases, pharmacotherapy becomes even more important. Unfractionated heparin, other heparins, synthetic protease inhibitors, recombinant thrombomodulin, and direct oral anticoagulants (DOACs) are agents that inhibit serine proteases, and all are effective against DIC. Inhibition of activated coagulation factors by anticoagulants is key to the treatment of DIC. Among them, DOACs can be taken orally and is useful for outpatient treatment. Combination therapy of heparin and nafamostat allows fine-adjustment of anticoagulant and antifibrinolytic effects. While warfarin is an anticoagulant, this agent is ineffective in the treatment of DIC because it inhibits the production of coagulation factors as substrates without inhibiting activated coagulation factors. In addition, monotherapy using tranexamic acid in cases of enhanced-fibrinolytic-type DIC may induce fatal thrombosis. If tranexamic acid is needed for DIC, combination with anticoagulant therapy is of critical importance.
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Yamada S, Asakura H. Management of disseminated intravascular coagulation associated with aortic aneurysm and vascular malformations. Int J Hematol 2020; 113:15-23. [PMID: 33175341 DOI: 10.1007/s12185-020-03028-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/04/2020] [Accepted: 10/22/2020] [Indexed: 11/25/2022]
Abstract
Aortic aneurysms and vascular malformations are sometimes associated with disseminated intravascular coagulation (DIC). A typical blood coagulation test shows decrease in platelet count and fibrinogen, and increases in fibrin/fibrinogen degradation products (FDP) and D-dimer. The coagulation activation marker thrombin-antithrombin complex (TAT) and the fibrinolysis activation marker plasmin-α2 plasmin inhibitor (PIC) are significantly increased. α2 plasmin inhibitor (α2PI) is significantly reduced. Since no prolongation of prothrombin time (PT) is noticeable and activated partial thromboplastin time (APTT) is shortened in some cases, DIC cannot be diagnosed or ruled out by PT and APTT alone. The cornerstone of treatment for DIC is to treat the underlying disease. However, surgery is not possible in some cases. Follow-up may be appropriate in patients with abnormal results from coagulation tests and no bleeding. However, pharmacotherapy is often required in cases with bleeding. Unfractionated heparin, low molecular weight heparin, protease inhibitors, recombinant thrombomodulin, direct oral anticoagulants, and factor XIII preparations are effective. If PIC is significantly increased and α2PI is significantly decreased, or if the bleeding is severe, tranexamic acid is used as an antifibrinolytic therapy with anticoagulant therapy. In such cases, attention should be paid not only to TAT but also changes in PIC.
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Affiliation(s)
- Shinya Yamada
- Department of Hematology, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan
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Jiménez-Altayó F, Meirelles T, Crosas-Molist E, Sorolla MA, Del Blanco DG, López-Luque J, Mas-Stachurska A, Siegert AM, Bonorino F, Barberà L, García C, Condom E, Sitges M, Rodríguez-Pascual F, Laurindo F, Schröder K, Ros J, Fabregat I, Egea G. Redox stress in Marfan syndrome: Dissecting the role of the NADPH oxidase NOX4 in aortic aneurysm. Free Radic Biol Med 2018; 118:44-58. [PMID: 29471108 DOI: 10.1016/j.freeradbiomed.2018.02.023] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/12/2018] [Accepted: 02/15/2018] [Indexed: 11/16/2022]
Abstract
Marfan syndrome (MFS) is characterized by the formation of ascending aortic aneurysms resulting from altered assembly of extracellular matrix fibrillin-containing microfibrils and dysfunction of TGF-β signaling. Here we identify the molecular targets of redox stress in aortic aneurysms from MFS patients, and investigate the role of NOX4, whose expression is strongly induced by TGF-β, in aneurysm formation and progression in a murine model of MFS. Working models included aortae and cultured vascular smooth muscle cells (VSMC) from MFS patients, and a NOX4-deficient Marfan mouse model (Fbn1C1039G/+-Nox4-/-). Increased tyrosine nitration and reactive oxygen species levels were found in the tunica media of human aortic aneurysms and in cultured VSMC. Proteomic analysis identified nitrated and carbonylated proteins, which included smooth muscle α-actin (αSMA) and annexin A2. NOX4 immunostaining increased in the tunica media of human Marfan aorta and was transcriptionally overexpressed in VSMC. Fbn1C1039G/+-Nox4-/- mice aortas showed a reduction of fragmented elastic fibers, which was accompanied by an amelioration in the Marfan-associated enlargement of the aortic root. Increase in the contractile phenotype marker calponin in the tunica media of MFS mice aortas was abrogated in Fbn1C1039G/+-Nox4-/- mice. Endothelial dysfunction evaluated by myography in the Marfan ascending aorta was prevented by the absence of Nox4 or catalase-induced H2O2 decomposition. We conclude that redox stress occurs in MFS, whose targets are actin-based cytoskeleton members and regulators of extracellular matrix homeostasis. Likewise, NOX4 have an impact in the progression of the aortic dilation in MFS and in the structural organization of the aortic tunica media, the VSMC phenotypic modulation, and endothelial function.
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Affiliation(s)
- Francesc Jiménez-Altayó
- Departament de Farmacologia, Terapèutica i Toxicologia, Institut de Neurociències, Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Thayna Meirelles
- Department de Biomedicina, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, and IDIBAPS, Barcelona, Spain
| | - Eva Crosas-Molist
- TGF-β and Cancer Group, Oncobell Program, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - M Alba Sorolla
- Institut de Recerca Biomèdica de Lleida (IRB Lleida), Lleida, Spain; Departament de Ciències Mèdiques Bàsiques, Universitat de Lleida, Lleida, Spain
| | - Darya Gorbenko Del Blanco
- Department de Biomedicina, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, and IDIBAPS, Barcelona, Spain
| | - Judit López-Luque
- TGF-β and Cancer Group, Oncobell Program, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Ana-Maria Siegert
- Department de Biomedicina, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, and IDIBAPS, Barcelona, Spain
| | - Fabio Bonorino
- Department de Biomedicina, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, and IDIBAPS, Barcelona, Spain
| | - Laura Barberà
- Department de Biomedicina, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, and IDIBAPS, Barcelona, Spain
| | - Carolina García
- Department of Pathology, Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, and Department of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain
| | - Enric Condom
- Department of Pathology, Hospital de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, and Department of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain
| | - Marta Sitges
- Cardiovascular Institute, Hospital Clinic, IDIBAPS-University of Barcelona, Barcelona, Spain
| | | | - Francisco Laurindo
- Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil
| | - Katrin Schröder
- German Center of Cardiovascular Research (DZHK), Partner site Rhein Main, Frankfurt am Main, Germany
| | - Joaquim Ros
- Institut de Recerca Biomèdica de Lleida (IRB Lleida), Lleida, Spain; Departament de Ciències Mèdiques Bàsiques, Universitat de Lleida, Lleida, Spain
| | - Isabel Fabregat
- TGF-β and Cancer Group, Oncobell Program, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain; Department de Ciències Fisiològiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Gustavo Egea
- Department de Biomedicina, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, and IDIBAPS, Barcelona, Spain.
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Ciccarelli M, Sorriento D, Franco A, Fusco A, Giudice CD, Annunziata R, Cipolletta E, Monti MG, Dorn GW, Trimarco B, Iaccarino G. Endothelial G protein-coupled receptor kinase 2 regulates vascular homeostasis through the control of free radical oxygen species. Arterioscler Thromb Vasc Biol 2013; 33:2415-24. [PMID: 23950144 PMCID: PMC4262246 DOI: 10.1161/atvbaha.113.302262] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The role of endothelial G protein-coupled receptor kinase 2 (GRK2) was investigated in mice with selective deletion of the kinase in the endothelium (Tie2-CRE/GRK2(fl/fl)). APPROACH AND RESULTS Aortas from Tie2-CRE/GRK2(fl/fl) presented functional and structural alterations as compared with control GRK2(fl/fl) mice. In particular, vasoconstriction was blunted to different agonists, and collagen and elastic rearrangement and macrophage infiltration were observed. In primary cultured endothelial cells deficient for GRK2, mitochondrial reactive oxygen species was increased, leading to expression of cytokines. Chronic treatment with a reactive oxygen species scavenger in mice corrected the vascular phenotype by recovering vasoconstriction, structural abnormalities, and reducing macrophage infiltration. CONCLUSIONS These results demonstrate that GRK2 removal compromises vascular phenotype and integrity by increasing endothelial reactive oxygen species production.
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Affiliation(s)
- Michele Ciccarelli
- University of Salerno, Salerno, Italy
- Temple University, Philadelphia, USA
| | | | | | | | | | | | | | | | | | | | - Guido Iaccarino
- University of Salerno, Salerno, Italy
- IRCCS “multimedica”, Milan, Italy
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Pinheiro R, Eloy A, Alves F, Andrioli A, Santiago L. Thoracic aortic aneurysm in a buck associated with caseous lymphadenitis. ARQ BRAS MED VET ZOO 2013. [DOI: 10.1590/s0102-09352013000300012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
This paper reports the clinical, bacteriological and pathological findings of a thoracic aortic aneurysm in a four-year-old Anglo-Nubian goat buck, related to a framework of visceral caseous lymphadenitis. General clinical examination showed heart rate of 75 beats per minute, respiratory rate of 20 movements per minute and ruminal movements of four movements per minute. Superficial lymph nodes were normal upon palpation. Rectal temperature was slightly high (40.5°C). Blood test showed an intense leukocytosis (54,000/µL), characterized by strong neutrophil shift to the left. At necropsy, a large blood clot was detected in the thoracic cavity. The thickening of the myocardium and dilatation of the aorta in the thoracic portion, presenting a saculiform format was also observed. A large number of abscesses were disseminated in the media and intima layers of aorta. The aorta lumen obstruction by arterial plaques consisting of inflammatory infiltrate, predominantly neutrophilic was also detected. Abscesses were found spread in turbinate, rumen, reticulum, kidneys, liver, spleen, testicles and aorta wall. The microbiological exam of exudate confirmed Corynebacterium pseudotuberculosis as the causal agent.
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Borges LF, Gomez D, Quintana M, Touat Z, Jondeau G, Leclercq A, Meilhac O, Jandrot-Perrus M, Gutierrez PS, Freymuller E, Vranckx R, Michel JB. Fibrinolytic activity is associated with presence of cystic medial degeneration in aneurysms of the ascending aorta. Histopathology 2010; 57:917-32. [DOI: 10.1111/j.1365-2559.2010.03719.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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