Egyptian Vascular and Endovascular Society - EVES’ Post

Transcript

Good morning. I am Ahmed. The professor of hospital surgery in chunks university president african. President, American Federation of Georgia, vascular surgeon and founder of vascular surgery department as one universe. As part of the activities of the 1st Congress of ES, the Egyptian Vascular and the Western Society. It's a pleasure to host today Professor Eduardo Ramaciotti from Brazil, Sao Paulo. And his professional vascular surgeon. University Chicago and Santa Casa University in Sao Paulo. And we are going to be like chatting together. What I consider a vital. The topic What research? We need tomorrow for the available anticoagulants for having hands today. Can I start, Eduardo, by saying that we are aware of the downside of the available anticoagulants we have in hand right now? Not only because of fear of bleeding in so many patients, but also certain. Is het ook paarsen. Inefficiency as well as. For how long? I'm talking about dosage and duration. Be it prophylaxis for B. Entergy. So I'd like to have your input on that please. Excellent. It's a pleasure to be here, Professor Emma. Well, we have some gaps with the development of the current anticoagulants and let us talk about factor 10 inhibition and factor 2 inhibition, bearing in mind that we are developing the factory 11 inhibitor which is trying to fill up these gaps. So which gaps are these? Number one for vascular surgeons, chronic kidney disease and renal insufficiency, we cannot use dogs in patients. Dialysis but a pizza burnt that is approved by the FDA but no trials. So this is one of the major gaps that we need further research. Can we adjust the dose of all these dogs and use it in chronic kidney disease like we did in atrial fibrillation? Can we double adjust it and use in patients with dialysis? So this is the number one question for vascular surgeons with dogs that we need to address. The other one, professor, is cryptogenic strokes. Half of the strokes does not come from 8 to fibrillation and those strokes are those sclerotic or cryptogenic and the recurrence rates are very high with clopidogrel and aspirin. We tried the dogs and we failed due to bleeding. So further research is needed if factory 11 fails. Can I just interrupt you for a second? Yes, I'm concerned about the. Anti-inflammatory effect which is probably lacking most of the device. Any potential for research in that area? Well, professional, we did it and we don't have much of anti-inflammatory effects which such small molecules they're different from happening and from low molecular weight heparin in terms of size of the model. They act kind of I won't say similar, but they have the same upset in, in, in the same offset. But there's small molecules in the anti-inflammatory effects are very small with these molecules. So I don't imagine we're pursuing new, new, new research in this area, but. I think the focus should be in the gaps we're discussing. So gap #1 chronic kidney disease, gap #2 is. Bleeding and these issues and we have some other gaps. I'll give you an example, anti phospholipid syndrome. Patients triple positive for anti phospholipid syndrome, how do we treat them? We trend to use the wax but they were stopped because of one trial that showed increase in the number of arterial events. So we today we need to give Warframe for these patients. INR 3.5 plus aspirin and I believe we should test higher doses of dogs in this population as well. Big gap anti phospholipid syndrome and dogs. Out of like. Real life scenario. I'll give you an example. Supposedly I am. I'm patient hospitalized. Ask you about two intentions scenarios. I'm almost in the ICU. Hospitalized, but not. And then the doctor comes and then tells me. Unfractionated. Or. No molecular weights happens. 1. Supposedly you gave me an option to choose from. So sorry again, Repeat supposed they supposedly are in the ICU, and then they come and tell me we're gonna give you IV shots of unfractionated heparin. More of you have the option my veins are bad, can I take it sometimes? So which is good and bad about these two options? Well for the ICU and even for the ward for VTE prophylaxis by guidelines we should use either heparin or low molecular weight heparin because dogs failed. We have river rocks upon approved in the US with a combination of two failed trials. Which was the Mariner while I'm one of the co-authors of the Mariner and and the Magellan trial so. This is an important question for the ICU because we have again a fair number of patients in the ICU with creatinine clearance levels below 30 and for then we should use unfractionated heparin. This is the best data we have and you can use unfractionated heparin in these patients with poor lines subcutaneously you have the presentation of points 25ML's of unfractionated happening in some countries. We have it. I don't know if you have it. You're in Egypt, but you can use unfractionated heparin 5000 units every 12 hours of every eight hours for these patients or low molecular weight happening. The question is adjusting the dose for those ICU patients, does it work? We don't have an answer yet. So again, for the current anticoagulants, we have space for clinical research and I'll give you another very important indication that I'm working right now. It's a little molecular weight happens, which is the pregnant woman and the poor period, period. And I'll give you numbers and in my country we have 2,600,000 deliveries per year. How much 2,600,000 deliveries per year in the US, 3,600,000. And these women, they undergo SIS action, which is a major abdominal surgery. And they are exposed to the risk of cardiac of unistream womble is to the highest. And we do not have proper trials addressing the poor period, period. And we know that 40 milligrams of enoxaparin is not enough. The high load trial last year showed 13% of events in women and the poor period with the high Royal College of Gynecology and Obstetrics score 13% of events with 40 milligrams too much. So we are now conducting a trial where we're increasing the dose of low molecular weight. Spring for the poor period, period. It's going to be a global trial. We're we're very happy to be conducting it because it's a major gap Women's Health. We did not pay attention to pregnancy cycle when we develop in our suffering pregnancies, of course, too much of A concern. That all of us yes, that's a that's the point that needs probably further research because who comes into play action. Apart from us as vascular surgeries, I think it would be a gynecologist. And of course there's always that fear of patients herself losing the baby or whatever and then the addition of therapy genericity, which is more hypothetical than more fear than real, actual. So that's a that's an area worthy of some further research and also those patients with. Of this function yes for the pregnancy and this use of heparin or low molecular weight heparin to prevent fetal loss. We have recent data from the our live trial from Saskia Meador and guess what love molecular weight heparin did not protect these women from losing their babies. The number of successful deliveries in the placebo arm was 71% versus 72% in INOX supporting are. So the conclusion is that maybe in offspring doesn't work to prevent fetal losses in women with thrombophilia. We need further research in the trial has just 300 patients. So this is something we need to invest. And the only clear data we have is that we need to give anticoagulants for pregnant women with anti phospholipid syndrome. This one we should give full dose of Lomography. It's kind of clear for those without anti phospholipid syndrome with a factor of. I've lived in notation. For example, you don't have proper data and the current data shows store. Surprise that the Knox supreme doesn't work. Do we have? Including. And this very interesting chat. For me. By asking you, uh, do we have? Ethical committee approval issues at all were designing further studies like this. Yes we do and and we have a point. Even the fact that we can use low molecular weight heparin and pregnant women because it's sugar. And bearing in mind that we have a fair number of women dying by pulmonary embolism in the pregnancy setting and the poor barium setting, properly conducted trials comparing low dose to high dose will be approved by Ethics Committee for sure. Then that really thank you so much for this wonderful exchange and I do hope to be position that soon. Those potential areas of worthy sort of research. The forthcoming meeting, yes. So thank you again and welcome to. It's my pleasure to be here, Professor Rahman.