Addition of TXA to a restrictive transfusion protocol makes the use of a postoperative blood salvage system in patients undergoing primary hip and knee arthroplasty unnecessary.

No abstract

Thromboembolic occlusion of peripheral arteries is a common problem in patients referred to vascular surgery departments. Standard treatments include catheter aspiration techniques, use of fibrinolytic agents and surgical thrombendarterectomy. Recent reports have described the use of hyperbaric oxygen therapy in patients with limb ischemia, yet their main focus has been on patients with chronic disorders. We present the case of a 74-year-old woman with atrial fibrillation and acute thromboembolic occlusion of the posterior tibial artery. The patient presented with severe pain in the right calf, unresponsive to non-opioid parenteral analgesia and accompanied by coldness, numbness and partial motor palsy of the right foot. After 60 minutes of oxygenation in a hyperbaric chamber with a pressure of 2.2 bar, the pain receded, although without signs of restored blood flow in the occluded artery. After fibrinolytic therapy with streptokinase, patency of the posterior tibial artery was verified by return of palpable pulsations and color Doppler ultrasonography. By combining hyperbaric oxygenation and streptokinase in the treatment of lower-leg arterial thromboembolism we achieved regression of ischemic pain, prolongation of the survival time of tissues compromised by ischemia and resolved the cause of the ischemia. We believe the use of this therapeutic strategy in selected cases of peripheral arterial thromboembolism is justified.

We read with great interest the article by Calligaro et al (J Vasc Surg 2003;38:1170-7) describing their experiences with acute arterial complications related to hip and knee arthroplasty. We find one major point of concern in their work. The authors stated that "patients did not receive routinely anticoagulation therapy" after urgent vascular surgery performed in those patients developing signs of acute arterial complications shortly after arthroplasty. Although the question of routine thromboprophylaxis after major orthopedic surgery has been raised before 1 and is also an issue of debate in vascular surgery, 2,3 current guidelines still recommend some form of prophylaxis to be used in such patients. Since in patients undergoing lower extremity arthroplasty, an intense activation of the clotting cascade 4 is associated with venous stasis and endothelial injury caused by kinking of the femoral vein during intraoperative lower extremity manipulation, these patients are at high risk for venous thromboembolism. 5 The use of a tourniquet during total knee arthroplasty is an additional risk factor. Subsequent vascular surgery can only heighten the risk for venous thromboembolism in such patients.Although thromboprophylaxis was not a focus of their work, the authors should have clearly stated on what grounds they chose to go against current guidelines and omit postoperative anticoagulation in such high-risk patients. It should also have been noted whether their patients received some other form of thromboprophylaxis (eg, intermittent pneumatic compression) and how early passive and active limb mobilization was begun. These are points crucial to any patient undergoing total hip or knee arthroplasty.