Os progestagênios isolados são contraceptivos indicados que em trombofílicas e/ou com passado de tromboembolismo venoso (TEV). Algumas dessas mulheres, também utilizam anticoagulantes orais (ATCO) o que pode implicar em alterações no padrão de sangramento menstrual associado ao uso de progestagênios isolados. Objetivo: avaliar os efeitos do uso de ATCO no padrão de sangramento associado ao sistema intrauterino liberador de levonorgestrel (SIU-LNG) em mulheres trombofílicas e/ou com passado de TEV . Métodos: Trata-se de um estudo de coorte prospectiva que dividiu as mulheres trombofílicas e/ou com passado de TEV em dois grupos, usuárias de ATCO e não-usuárias de ATCO. Padrão de sangramento, peso, índice de massa corpórea (IMC) e circunferência abdominal foram comparados entre os grupos antes, 6 e 12 meses após a inserção do SIU-LNG. Resultados: Foram incluídas 33 mulheres, entre 18 e 45 anos, 16 usuárias de ATCO e 17 não-usuárias. Houve aumento de 3,9% do peso e 3,8% do IMC em das usuárias de ATCO após 12 meses da inserção do SIU-LNG (p<0,01). Houve aumento de hemoglobina e hematócrito em ambos os grupos. Não se observou diferença entre o padrão de sangramento de ambos os grupos, sendo a amenorréia o padrão mais frequente nos dois grupos (41,2% em ambos) 12 meses após a inserção do SIU-LNG. Utilizar ATCO não aumentou a freqüência e a duranção de sangramento genital. Conclusão: As usuárias e não-usuárias de ATCO tiveram padrão de sangramento semelhante após a inserção do SIU-LNG. Os níveis de hemoglobina e hematócrito aumentaram em ambos os grupos / Background: Progestogen-only contraceptives (POCs) are suitable for women with thrombophilia and/or a history of venous thromboembolism (VTE). Several of these women, however, use oral anticoagulant therapy (OAT), which can impair the bleeding pattern associated with POC use. We evaluated the effects of OAT use on the bleeding pattern associated with the levonorgestrel-releasing intrauterine system (LNG-IUS) in women with thrombophilia and/or a history of VTE. Study Design: This prospective cohort study followed 2 groups of women, all of whom were thrombophilic and/or had a history of VTE: OAT users and non-users. Bleeding patterns, blood pressure, body mass index (BMI), weight, complete blood count and waist circumference were compared between the 2 groups before and 6 and 12 months after LNG-IUS insertion. Results: The patient cohort consisted of 33 women aged 18 to 45 years old, including 16 OAT users and 17 non-users. Body weight increased by 3.9% and BMI by 3.8% in OAT users 12 months after LNG-IUS insertion (p< 0,01). Hemoglobin and hematocrit levels increased by approximately 10% in both groups. There was no difference between the groups in bleeding patterns, with amenorrhea being the most frequent pattern in both groups (41.2% each) 12 months after LNG-IUS insertion. OAT did not increase the frequency of prolonged and/or frequent bleeding. Conclusion: OAT users and non-users had similar bleeding patterns after insertion of the LNG-IUS. Hemoglobin and hematocrit levels increased in both groups

Os progestagênios isolados são contraceptivos indicados que em trombofílicas e/ou com passado de tromboembolismo venoso (TEV). Algumas dessas mulheres, também utilizam anticoagulantes orais (ATCO) o que pode implicar em alterações no padrão de sangramento menstrual associado ao uso de progestagênios isolados. Objetivo: avaliar os efeitos do uso de ATCO no padrão de sangramento associado ao sistema intrauterino liberador de levonorgestrel (SIU-LNG) em mulheres trombofílicas e/ou com passado de TEV . Métodos: Trata-se de um estudo de coorte prospectiva que dividiu as mulheres trombofílicas e/ou com passado de TEV em dois grupos, usuárias de ATCO e não-usuárias de ATCO. Padrão de sangramento, peso, índice de massa corpórea (IMC) e circunferência abdominal foram comparados entre os grupos antes, 6 e 12 meses após a inserção do SIU-LNG. Resultados: Foram incluídas 33 mulheres, entre 18 e 45 anos, 16 usuárias de ATCO e 17 não-usuárias. Houve aumento de 3,9% do peso e 3,8% do IMC em das usuárias de ATCO após 12 meses da inserção do SIU-LNG (p<0,01). Houve aumento de hemoglobina e hematócrito em ambos os grupos. Não se observou diferença entre o padrão de sangramento de ambos os grupos, sendo a amenorréia o padrão mais frequente nos dois grupos (41,2% em ambos) 12 meses após a inserção do SIU-LNG. Utilizar ATCO não aumentou a freqüência e a duranção de sangramento genital. Conclusão: As usuárias e não-usuárias de ATCO tiveram padrão de sangramento semelhante após a inserção do SIU-LNG. Os níveis de hemoglobina e hematócrito aumentaram em ambos os grupos / Background: Progestogen-only contraceptives (POCs) are suitable for women with thrombophilia and/or a history of venous thromboembolism (VTE). Several of these women, however, use oral anticoagulant therapy (OAT), which can impair the bleeding pattern associated with POC use. We evaluated the effects of OAT use on the bleeding pattern associated with the levonorgestrel-releasing intrauterine system (LNG-IUS) in women with thrombophilia and/or a history of VTE. Study Design: This prospective cohort study followed 2 groups of women, all of whom were thrombophilic and/or had a history of VTE: OAT users and non-users. Bleeding patterns, blood pressure, body mass index (BMI), weight, complete blood count and waist circumference were compared between the 2 groups before and 6 and 12 months after LNG-IUS insertion. Results: The patient cohort consisted of 33 women aged 18 to 45 years old, including 16 OAT users and 17 non-users. Body weight increased by 3.9% and BMI by 3.8% in OAT users 12 months after LNG-IUS insertion (p< 0,01). Hemoglobin and hematocrit levels increased by approximately 10% in both groups. There was no difference between the groups in bleeding patterns, with amenorrhea being the most frequent pattern in both groups (41.2% each) 12 months after LNG-IUS insertion. OAT did not increase the frequency of prolonged and/or frequent bleeding. Conclusion: OAT users and non-users had similar bleeding patterns after insertion of the LNG-IUS. Hemoglobin and hematocrit levels increased in both groups

Η θρόμβωση αποτελεί το πιο συχνό αίτιο δυσλειτουργίας της αγγειακής προσπέλασης, στους ασθενείς, με νεφρική ανεπάρκεια τελικού σταδίου, που υποβάλλονται σε αιμοκάθαρση. Σκοπός: Στόχος της παρούσας μελέτης είναι η εκτίμηση του ρόλου του προεγχειρητικού απεικονιστικού ελέγχου στη δημιουργία αγγειακής προσπέλασης και ο έλεγχος των παραγόντων που επηρεάζουν τη βιωσιμότητα της. Εκτιμήθηκε η επίδραση της διαμέτρου των αγγείων, που χρησιμοποιούνται στη δημιουργία αγγειακής προσπέλασης, στη βατότητα αυτής. Ελέγχθηκε ο ρόλος των γονιδιακών θρομβοφιλικών παραγόντων (FV Leiden, FII G20210A και MTHFR C677T→A) στην παρουσία θρόμβωσης και στην επιβίωση της ΑΦΕ. Τέλος ελέγχθηκε η δυνατότητα πρόβλεψης της θρόμβωσης με τη χρήση δημογραφικών, αιμοδυναμικών, αιματολογικών και βιοχημικών παραγόντων, αλλά και των θρομβοφιλικών γονιδιακών μεταλλάξεων. Μέθοδος- Υλικό: 137 συνεχόμενα περιστατικά, από Μάρτιο 2005 έως Δεκέμβριο 2006, προσήλθαν για δημιουργία αγγειακής προσπέλασης για αιμοκάθαρση και εντάχθηκαν στην παρούσα μελέτη. Μετά από φυσική εξέταση και λήψη ιστορικού, κατεγράφη το αιματολογικό- βιοχημικό τους προφίλ και η παρουσία θρομβοφιλικών μεταλλάξεων. Υπεβλήθηκαν σε χαρτογράφηση των αγγείων των άκρων με χρήση υπερήχων και φλεβογραφία και συνυπολογίζοντας όλα τα δεδομένα ακλούθησε η δημιουργία αγγειακής προσπέλασης. Δημιουργήθηκαν 26 περιφερικές ΑΦΑ, 74 κεντρικές ΑΦΑ, τοποθετήθηκαν 32 ΑΦΜ και σε 5 περιστατικά ετέθη μόνιμος καθετήρας. Εξαιρέθηκαν από τη μελέτη τα περιστατικά με πρώιμη θρόμβωση (9), τα περιστατικά που δεν χρησιμοποιήθηκε η αγγειακή προσπέλαση (11) και στα περιστατικά που χάθηκαν από την παρακολούθηση η απεβίωσαν πριν συμπληρωθούν τουλάχιστον 4 μήνες ελέγχου (14). Στα υπόλοιπα 102 περιστατικά έγινε υπερηχογραφικός έλεγχος της αγγειακής προσπέλασης στους 2, 6 και 12 μήνες και κλινική εκτίμηση έως το πέρας της μελέτης σε τακτά χρονικά διαστήματα. Αποτελέσματα: Η USVM άλλαξε το προεγχειρητικό σχεδιασμό σε 31 (22.6%) ασθενείς, χωρίς να αλλάξει η τελική αναλογία του τύπου σε σύγκριση με την αρχική εκτίμηση. 18 ασθενείς (36.7%) που τα υπερηχογραφικά ευρήματα άλλαξαν το σχεδιασμό ήταν διαβητικοί σε σύγκριση με το 14.8% (13) σε μη διαβητικούς (p<.001). Στα περιστατικά που άλλαξε το σχεδιασμό η USVM υπήρξαν για μεγαλύτερο χρονικό διάστημα σε πρόγραμμα αιμοκάθαρσης(2.7 vs. 0.9 έτη). Φλεβογραφικά αναγνωρίστηκαν 18 περιστατικά με κεντρική στένωση και σε 12 από αυτά άλλαξε ο σχεδιασμός. Σημαντική στένωση παρουσίασε το 93% των ασθενών που στο ιστορικό ανέφεραν πάνω από 2 τοποθετήσεις κεντρικών καθετήρων. Η διάμετρος της φλέβας στις αναστομώσεις που παρουσίασαν πρώιμη θρόμβωση υπήρξε μικρότερη από τις υπόλοιπες λιτουργικές ΑΦΑ (2.84 vs 3.94, p<.001). Οι ΑΦΕ που παρουσίασαν θρόμβωση παρουσίασαν αρχική παροχή (Qa) 558.13 ml/min σε σύγκριση με τα 821.26 ml/min των περιστατικών που δεν παρουσίασαν θρόμβωση. Τα περιστατικά που παρουσίασαν θρόμβωση είχαν υψηλότερη συγκέντρωση Lp(a), είχαν ενταχθεί για μεγαλύτερο χρόνο σε αιμοκάθαρση και παρουσίαζαν μετάλλαξη του MTHFR (R2=0.6, p<.001). Οι γυναίκες, τα μοσχεύματα, ο χαμηλότερος όγκος ροής και η παρουσία μετάλλαξης FV Leiden σχετίζονται με συχνότερη εμφάνιση θρόμβωσης (p<.05). Συμπεράσματα: Ο υπερηχογραφικός έλεγχος θα πρέπει να γίνεται συστηματικά στον προεγχειρητικό σχεδιασμό, με μεγαλύτερο όφελος στους διαβητικούς, σε άτομα με περισσότερο χρόνο σε αιμοκάθαρση, με ιστορικό άλλων επεμβάσεων αγγειακής προσπέλασης. Η φλεβογραφία θα πρέπει να γίνεται σε όλους τους ασθενείς με ιστορικό τοποθέτησης κεντρικής γραμμής στην πλευρά του χειρουργείου. Η πρώιμη θρόμβωση της ΑΦΕ συνδέεται με μικρότερη διάμετρο της φλέβας προς αναστόμωση. Ο Qa αποτελεί αξιόπιστο δείκτη καλής λειτουργίας της ΑΦΕ. Η θρόμβωση εμφανίζεται πιο συχνά στις γυναίκες, στους ασθενείς με αυξημένα επίπεδα Lp(a), σε ατόμα με περισσότερα χρόνια σε αιμοκάθαρση και στα ΑΦΜ. Τόσο ο FV Leiden όσο και το MTHFR φαίνεται να παίζουν ρόλο στην εμφάνιση θρόμβωσης στις ΑΦΑ. / Vascular access thrombosis (VAT) is one of the most common causes of morbidity in hemodialysis patients. Objective: In an effort to increase the prevalence of AV fistulae, ultrasound vessel mapping (USVM) and upper extremity venography (UEV) have been suggested; however the effectiveness of their combined use remains unknown. We studied the effect of such a combined protocol on AV access type change, compared to physical examination alone. The vascular access patency had been correlated to vessel diameter and to a number of thrombosis risk factors. Finally the role of genetic thrombophilic risk factors on vascular access thrombosis was studied. Methods: Consecutive cases with chronic kidney disease (n=137) after an initial estimation of the AV access type based on physical examination, had USVM and UEV, to detect vascular pathology that could potentially alter the original plan. 26 distal AVF, 74 central AVF, 32 AV grafts and 5 permanent catheters were placed. 9 cases presented early thrombosis, 11 cases had delayed first use or the access wasn’t used at all, 14 patients died or did not present at their follow up and were excluded from our study. On the remaining 102 cases an ultrasound control of the VA was performed on 2, 6 and 12 months and clinical evaluation of the VA was performed in a regular base. Results: USVM changed the preoperative plan in 22.6% (31) patients; this was 36.7% (n=18) in diabetics compared to 14.8% (n=13) in non-diabetics (p<.001). Patients that USVM changed the type of the planned AV access had been on hemodialysis significantly longer (2.7 years vs. 0.9 years, p<.001). Venography identified 18 patients with central vein stenosis that led to a site change in 12 of them. Significant venous stenosis in patients with history of two or more central catheters placed and without such was 93%.Original plan was revised in 31% and this rate was similar for distal AVFs, central AVFs and AV grafts (38%, 26% and 43%, respectively, all p>0.05). The internal vein diameter used in VA creation was significant smaller in cases of early thrombosis (2.84 vs 3.94, p<.001). Thrombosed VA presented with initial flow volume measurement (Qa) of 558.13 ml/min and was significantly lower than VA without thrombosis 821.26 ml/min. Thrombosis was more frequent in a) higher values of cholesterol and Lp(a), b) longer periods under hemodialysis, b) lower blood flow volume in initial testing and with existence of MTHFR mutations. VA was thrombosed sooner in women, when an AV graft was placed and in FV Leiden mutation (p<.05). Conclusions: A significant proportion of patients have vascular pathology severe enough to alter the access type as suggested by physical examination alone. USVM should be routinely performed, while UEV selectively in patients with history of surgery or instrumentation of their central veins. The early thrombosis of VA appears on a smaller vein diameter. The blood flow volume measurement is a reliable indicator in case of vascular access thrombosis. Thrombosis appears in greater proportion in women, in higher Lp(a) concentration, in AV grafts. Finally FV Leiden and MTHFR mutations seem to play a role in vascular access thrombosis.